Authorization for Release of Medical Information

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Compass Clinical Associates, PLLC

2500 82nd PLACE, URBANDALE, IA 50322 | 1-515-412-5112
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize the following parties*

Compass Clinical Associates, PLLC andThird Party Listed Below
Name*
Address*
Phone*
Please SELECT all that apply: *
The information is being requested for the following purpose(s):
By signing this form -

I understand that I may revoke this authorization by providing a written revocation to the parties named above at any time. I also understand that any information which has been released prior to the revocation may be used for the purposes listed above.

I understand that I may have a right to inspect disclosed information at any time and that such inspection will occur in a meeting with a member of the professional staff. I acknowledge that the information to be released may include material that is protected by state and/or federal law applicable to either mental health or substance abuse or both. My signature authorizes release of all such information.
This authorization is effective for one of the following:*

twelve months from the date on which it is signedindefinitely until revoked
Signature of Patient or Patient’s Authorized Representative *

Clear
If authorized Representative. Relationship to Patient
Date*

MonthDayYear
Date
PROHIBITION ON REDISCLOSURE

This form does not authorize redisclosure of Medical Information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for substance abuse records or by state law for mental health records, federal requirements (42 C.F.R. Part 2) and state requirements (Iowa code ch. 22) prohibits further disclosure without the specific written consent of the patient, or as otherwise permitted by such law and/or regulations. A general authorization for the release of medical or other Information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosure of substance abuse or mental health Information.
Should be Empty:

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Compass Clinical Associates, PLLC