I

give my consent to ARC Manor to disclose information from my patient record to: UPMC for the sole purpose of billing for services, eligibility determination, audits, quality management, and verification of coverage.

I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R., Chapter I, Part 2, and cannot be disclosed without my written consent unless otherwise permitted by the regulations.  I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.

I understand that I have no obligation whatsoever to disclose any information from my patient record and I understand that I may revoke this consent at any time by notifiying ARC Manor verbally or in writing. 

NOTICE TO RECIPIENT OF INFORMATION: This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identities a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see section 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at sections 2.12(c)(5) and 2.65.

This consent shall automatically expire: when the maximum benefit allowed is collected

Ending Date: Date of expiration for this release of information