Client Paperwork
Consent to Share Behavioral Health Information
MDHHS‑5515 · Michigan Department of Health and Human Services (current revision)
This is a state-of-Michigan form that lets you tell ICHANGE who we can — and cannot — share information about your behavioral health or substance-use treatment with. It is required for care that involves coordination with other providers, family members, or third parties.
The plain-language version: you stay in control of who sees your records.
Opens the official MDHHS page in a new tab. We link to the state page (not a hosted copy) so you always get the latest revision — MDHHS periodically updates the form.
Why we need this form
Under federal and state law, ICHANGE generally does not need your consent to share most types of your health information for treatment, payment, or care coordination. But your behavioral health and substance-use disorder records get an extra layer of protection. We need your written consent before we can share those specific records with other providers, health plans, family members, or anyone else you choose.
What you’ll be authorizing
The form lets you decide:
- Who can see your records (specific providers, family, attorneys, schools, etc.)
- What can be shared (everything, or only certain categories — like diagnosis, medications, lab results)
- How long the consent lasts (defaults to one year; you can set an earlier end date)
- Whether we can share through electronic health-information exchanges
Psychotherapy notes and substance-use counseling notes are never shared under this form — they require a separate, specific authorization.
How to complete & return it
- Download the form from the MDHHS link above.
- Fill it out — pay close attention to Sections 3 and 4, which name who can see your records and what records can be shared.
- Sign & date Section 5.
- Return the completed form by one of:
- Bringing it to your first session
- Emailing a scanned/photographed copy to intake@ichangeprocess.org
- Mailing the original to ICHANGE, PO Box 81172, Lansing, MI 48908
If you change your mind, you can revoke the consent at any time using Section 6 of the same form (or by contacting us in writing).
What we promise
- We will only share what you specifically authorize, with the specific parties you list.
- We will never use this form for civil, criminal, administrative, or legislative proceedings.
- We will keep the signed form in your secure record at ICHANGE.
- If you revoke consent, we will stop sharing immediately — though records already shared cannot be recalled.
For more on how we handle your health information generally, see our HIPAA Notice of Privacy Practices.