SAPI Release of information form

Substance Abuse Prevention/Resource Institute, LLC (SAPI) Authorization to Disclose Client Information
Client Name:*
Today's Date:*

MonthDayYear
Date
Date of Birth:*

MonthDayYear
Date
The following program is authorized to make disclosure: Substance Abuse Prevention/Resource Institute, LLC (SAPI)

The program is authorized to : Send, receive, and exchange information about my attendance and participation in SAPI 72 HR Driver Intervention Program.
My Attorney or Referral Source to whom disclosure will be made:*
☒to coordinate treatment ☒to gather assessment information for treatment planning

☒to gather information for ongoing treatment ☐other

Type of information to be disclosed:

☒progress notes ☒diagnostic assessment information ☒lab results☒HIV/AIDS testing or status

☒diagnosis ☒progress in treatment ☒urine testing ☒attendance ☒information on mental illness and/or treatment ☒prenatal care ☒pregnancy testing ☐other______________________________

Amount of information to be disclosed:

☒information covering the previous three months ☒information covering the most recent admission ☐other
Signature of client*

Clear
Date*

MonthDayYear
Date
Signature of staff or witness

Clear
Date

MonthDayYear
Date
Revocation: This authorization is subject to revocation at any time except to the extent the program or person who is to make the
Revocation: This authorization is subject to revocation at any time except to the extent the program or person who is to make the disclosure has already acted in reliance on it.

Signature of client or other authorized person to permit disclosure
Date

MonthDayYear
Date
This authorization expires (specify event, date, and/or condition): 120 days post discharge from programming

Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. 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 whom it pertains or as otherwise permitted by 42 C.F.R., 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 information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 [HIPAA], 45 C.F.R., parts 160 and 164. [These conditions apply to every

page disclosed and a copy of this authorization will accompany every disclosure.]
Should be Empty:

Substance Abuse Prevention/Resource Institute, LLC (SAPI) Authorization to Disclose Client Information