Authorization to Use/Disclose Information (individual form)

Authorization to Use/Disclose Information

Other (Non-Admission/Yearly Update packet)
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Social Security Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I hereby authorize Aspire Wellness Center, Inc. to use or disclose my protected health information as indicated below to:
Person or Agency
Phone Number

Area Code Phone Number
Fax Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
**Please select each line of requested contact for information to be released**
Request

Initial Psychiatric/Psychosocial Evaluation Verbal Discussion of Case Clinical Summary Medication History Visit Summary Notes ALL Substance Abuse Treatment Record Emergency Information (Emergency Contact) Sit in on Scheduled Appointments CX/Schedule/Confirm Appointments Provide Ride for Client Hospital Records (specify month/year to month/year) Laboratory Reports (specify dates in box below)
Labs/Hospital Records
**Please note that no substance abuse information may be released via electronic communication**

**Purpose for Release of Information**
Purpose for ROI

Coordination of Care w/Outside Provider Emergency Contact Probation/Parole Requirements
Coordination of Care w/Outside Provider
Specify
I understand that my express consent is required to release any health care information relating to testing, diagnosis and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug/alcohol treatment or use.
Signature

Clear
I understand that I may revoke this authorization at any time by notifying Amberleigh Yoegel, LCPC/Director of Compliance & Quality Assurance, in writing, and this authorization will be revoked.

I understand that Aspire Wellness Center, Inc. may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization, unless my treatment is related to research and the purpose of this authorization is to enable the protected health information described above to be used for such research.

I understand that information disclosed baded on this authorization may be subject to re-disclosure by the recipient, and no longer protected by Federal privacy regulations. I understand that I may request a copy of this form after I sign it.
Signature

Clear
Client/Authorized Representative

First Name Last Name
Relationship to Client
Witness
Aspire Wellness Center Staff
Date of Release

Month Day Year
Date
The requested records or information is about health care provided and is valid for one year from the start (date of signature) of this release or 90 days following discharge from this facility.
Should be Empty: