755 Lomax, Idaho Falls, ID, 83401 Phone (208) 932-4493
Consent for Release of Information
am requesting substance abuse services from Idaho’s publicly funded substance abuse system of care. As such I voluntarily authorize BPA Health, those Substance AbuseTreatment and Recovery Support Services (RSS) providers who are contracted to provide Treatment and RSS under Idaho’s publicly funded substance abuse system of care, and the Department of Health and Welfare (Department) to disclose my name, all necessary treatment information and my social security number to each other and the Department. This information will be disclosed for the following purposes: 1) To assist with referring me to appropriate types of care and guiding my treatment and recovery support; 2) To be entered into the Department’s common client database so that I will have one client number for any services received from the Department; 3) To process payment of costs for my treatment and recovery support services; 4) For monitoring compliance in the program; 5) For program audit and research including independent peer reviewers, contract monitors or researchers appointment by the Department; 6) For investigations related to fraud.
Furthermore, I authorize the disclosure of personal substance abuse treatment and recovery outcomes data collected by contracted Substance Abuse Treatment and RSS Providers, BPA Health and the Department to the Federal Center for Substance Abuse Treatment and its contracted data collection Agents.
Informed and Voluntary Consent for Treatment
The purpose of my participation, as a client, in the Idaho publicly funded substance abuse treatment program is to acquire knowledge, skills and attitudes supportive of a sober and more satisfying lifestyle.In addition to the potential positive outcomes likely to occur as a result of my participation, the following reasonably foreseen risks may occur, as they would in any other alcohol and drug treatment program: breach of confidentiality; negative reactions of group members; emotional stress from requirements of group interaction, self-disclosure; stress to relationships resulting from open discussion of issues, past traumas; and, stress to relationships resulting from participant behavioral changes, positive or negative, need to attend recovery support meetings, spend time in group and doing assignments.Providers will take steps to minimize or protect participants against potential risks by adhering to standards of confidentiality found both in Federal and State Code, and by informing and verifying client understanding of group rules. And, by intervening in and guiding appropriate disclosure, confrontation and resolution in group and in family conflict. Providers will assist clients in accessing sober support services and self-help groups where acceptance and stress reducing support is available.
This release may be revoked at any time either orally or in writing, except to the extent that action has already been taken in reliance on the release. I acknowledge that some information may include material that is protected by State and Federal regulations including Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 and the Health Information Portability and Accountability Act (HIPAA). Unless revoked as stated above, this consent expires automatically on:
I have read the above Consent to Release of Information, Informed and Voluntary Consent for treatment and the Revocation Clause. I agree I have been given the opportunity to question the above disclosures and consent for care and hereby do agree to the above identified Disclosures and Consent to Treatment.
Release of information
, hereby authorize Stewards of Recovery to request and/or Disclose information, verbal or written, of
Please check all applicable items requested belowThe records requested are for the following services:
Please check all applicable items request belowSpecific Information Requested:
The purpose of the disclosure authorized herein is to Coordination of Care(Purpose of disclosure, as specific as possible)
I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, as well as the Health Information Portability and Accountability Act (HIPAA) of 1996, 45 CFR Parts 160 and 164 Subparts A and E, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent any time, by either written or verbal notification, except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
I also understand that this authorization is voluntary and that I may refuse to sign this authorization. I understand that this agency may not condition treatment, payment, enrollment, or eligibility for benefits whether or not I sign this authorization, unless allowed by law. I understand that I may inspect or copy any information used or disclosed under this authorization.
All Stewards forms are located on the website, sor4life.com. By signing this document, I acknowledge that I have have accessed and read these forms.
Acknowledgment of Receipt of HIPPA Notice of Privacy PracticesAcknowledgment of Receipt of Informed Consent for TreatmentAcknowledgment of Receipt of Provider Choice ListAcknowledgment of Receipt of Informed Confidentiality of Drug Abuse PatientsAcknowledgment of Receipt of Client Rights