HIPPA Release Form

Park Valley Behavioral Health Care PLLC

Maxwell Centre, Suite 500
32 20th Street, Wheeling WV 26003

Phone: (304) 218 - 2023 Fax: (304) 907-4259

AUTHORIZATION FOR RELEASE OF PROTECTED SUBSTANCE USE DISORDER AND BEHAVIORAL HEALTH INFORMATION

The following form is to give consent to obtain and recieve records from your family members or other healthcare providers
Name*

First NameLast Name
Birth Date:*

MonthDayYear
Date
I authorize and give my consent for Park Valley Behavioral Health Care PLLC ("Park Valley")*

To release my records to the following facility or personTo obtain my records from the following facility or person
Facility or Person(s) you would like to release information to/from*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Information to be used or disclosed. I authorize the use and disclosure of the following records and information:*

Presence in treatment and datesDiagnosesEmergency room recordsHospital recordsPsychiatric evaluationCurrent & past medications and dosagesOutpatient progress notesConsultationsAdmission/Intake assessment and notesDischarge summaryPsychological testingX-ray reportsInstructions to schoolPhysician records/ notesInsurance/ benefit information and recordsLaboratory reportsDrug screen resultsBilling information and records
Purpose: I understand the information will be used for the purpose of:*

At the individual's requestCase managementAssessment/treatment/referralLegalReimbursementDisability applicationCoordination of careTransportation
Revocation and Expiration: I understand that I can revoke this authorization at any time. I may do so in writing. Revocation does not apply to information that has already been released. If not previously revoked, this authorization will terminate upon:

Upon termination of treatment1 year after date of signatureOther
Type of Transmission: I consent the information may be released via:*

VerballyIn writingElectronically
I understand that my substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I acknowledge that any disclosure carries with it the potential that a re-disclosure not protected by federal confidentiality rules. * The receiver of the information may not be bound by law to protect my information

I understand that proteted health information includes substance abuse treatment, involuntary commitment, HIV, AIDS, genetic diseases or conditions, birth control, and sexually transmitted diseases. I understand that the information released may include such information.

I understand that I may be denies services if I refused to consent to disclosure for purposes of treatment, payment, or healthcare operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
Signature*
Date*

MonthDayYear
Date
Should be Empty: