Authorization & Consent For Release Of Information: LIMA

Authorization & Consent For Release Of Information
Section I
Fields marked with an asterisk (*) are required to be completed. Failure to provide additional identifying information in Section I may result in the inability to respond to this request. This form is not a patient access request under 45 CFR 164.524. Records released pursuant to this authorization may include information concerning testing, diagnosis or treatment of HIV/AIDS, psychiatric and/or drug/alcohol treatment, and/or sexual assault.
Today's Date*

MonthDayYear
Date
Client Full Name*

First NameMiddle NameLast Name
Client Date of Birth*

MonthDayYear
Date
Section II
I hereby authorize the disclosure of health information about the above individual as follows.
Recipient (Person or Entity)*
Phone Number

Area CodePhone Number
Recipient (Person or Entity)
Phone Number

Area CodePhone Number
Section III
Reason(s) for Disclosure*

Coordination of CarePersonal RequestLegal/Court OrderFinancial
Health Information to be Disclosed*

Identifying information: name, DOB, sex, race, address, phone number, email.Service/Treatment History including date/time of appointments and type of services providedPsychosocial HistoryDiagnostic Assessment and DiagnosisTreatment Plans/Progress NotesThird Party Authorization (only what is discussed during session)Discharge SummaryHIV and AIDS related diagnosis and treatmentCurrent substance abuse treatment, recommendations, and involvement (see section IV)Financial/Invoicing (includes name and appointment dates)Other
Section IV
- I understand that my alcohol and drug abuse patient records are protected under the Federal regulations governing confidentiality of those records, (42 CFR Part 2), cannot be disclosed without my written consent unless otherwise provided for in the regulations.
- I understand that signing or refusing to sign this Release will not affect public benefits or services for which I am eligible, unless otherwise required by the regulations of the agency.
- I understand that the information disclosed pursuant to this authorization may be the subject of re-disclosure by the recipient without further protection.
- I understand this Release expires 365 days from the date it is signed unless otherwise indicated by me. I also understand that I may cancel this Release at any time in writing with my signature, and the date it is signed, and delivering it to Cornerstone of Hope. Canceling it applies to that day forward and not to information already shared.
Client Name*

First NameLast Name
Parent/Guardian (If client is under the age of 18)

First NameLast Name
Signature*

Clear
Should be Empty:

Authorization & Consent For Release Of Information

Section I

Section II

Section III

Section IV