Release of Information

Bridges Healthcare, Inc.

941-949 Bridgeport Avenue

Milford, CT 06460

Phone: (203) 878-6365 Fax: ( 203) 874-5252

Client's Name:

First NameLast Name

Date of Birth:

Date

Authorization Date:

MonthDayYear

Last 4 Digits of Social Security Number:

Expiration Date:

Date

Or Upon (Whichever Comes First):

Client's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I authorize Bridges Healthcare, Inc. to:

Name:

First NameLast Name

Organization:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Area CodePhone Number

Fax:

Area CodePhone Number

Relationship to Client:

Information to be Released or Obtained

(to the minimum necessary for the intended purposes)

Please Check All That Apply:

This information may be shared:

Purpose of Disclosure

Please Check All That Apply:

By signing below , I understand the following statements about my rights:

My records are protected under Federal and State law and cannot be released. without my written permission or a court order, and I may revoke consent in writing at any time, but the revocation will not have any effect on any actions the entity took before it received the revocation.
Refusal to disclose information may result in improper diagnosis or treatment, or denial of coverage for a claim for health benefits, or other insurance or other adverse consequences.
My refusal to sign this authorization will not affect my ability to obtain treatment , benefits or services for which I am eligible.
I can cross out any provision on this form with which i disagree.
I am entitled to a copy of this authorization form.
Signing this authorization is voluntary.
I understand that I have the right to revoke this authorization at any time.

I understand disclosure of information to be released may contain information that refers to treatment or diagnosis of alcohol or drug abuse. I understand that it cannot be re-disclosed without my specific consent.
I authorize disclosure of information that refers to treatment or diagnosis of HIV or AIDS. I understand that some individuals, about whom such disclosure has been made, have encountered discrimination from others in the areas of employment, housing, insurance or social/family relations.
I authorize disclosure of information that refers to treatment and/or diagnosis of a psychiatric illness.
I understand that information pursuant to this authorization may no longer be protected by law or regulation and may be re-disclosed to the recipient.
A photocopy of this form will be considered as valid as the original.

The confidentiality of this record is required under HIPAA and Chapter 899 of the Connecticut General Statuses. This material shall not be transmitted to anyone without consent or other authorization as provided in aforementioned statuses.
*Alcohol and /or Drug treatment records: This information has been disclosed to you from records protected by Federal confidentiality rule (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to who it pertains or as otherwise, permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
**HIV Related Information: This information has been disclosed to you from records whos confidentiality is protected by state law. State law prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by state law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

SUBSTANCE ABUSE RECORDS REQUIRE SIGNATURE OF ALL MINOR CLIENTS

Minor is defined by Connecticut General Statute's section 19a-14c as any child under the age of 18.

Client or Guardian Signature & Date:

By initialing and dating, I revoke my authorization to release or provide information from my record to the Person or Organization noted on this form.

I understand that the revocation does not apply to information that has already been released. Unless otherwise revoked, this authorization will expire as indicated.

If guardian is signing , please list name and relationship to client:

Bridges Healthcare Staff Signature & Date:

The following section is ONLY for the revocation of a release of confidential information after it has been completed and signed.

By initialing and dating, I revoke my authorization to release or provide information from my record to the Person or Organization noted on this form.

I understand that the revocation does not apply to information that has already been released. Unless otherwise revoked, this authorization will expire as indicated.

Client Intials & Date (For Revocation Only):

Authorization for Release of Confidential Information