• Release of Information Form

    AUTHORIZATION TO DISCLOSE / OBTAIN PROTECTED HEALTH INFORMATION
  • I, * , * hereby freely and voluntarily authorize Brownstone Psychiatry to disclose / obtain protected health information to the following entity.

  • My medical records may include information regarding my diagnosis and treatment of drug, alcohol, Acquired Immunodeficiency Syndrome, (HIV Serology) and Psychiatric Disorders. I understand such information is confidential and is protected by federal law. Those receiving this information will be advised that federal regulations (42 CFR part 2) prohibit their making further disclosure without my written consent or as otherwise permitted by such regulations.

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  • I understand that having the right to inspect and copy any written information disclosed and the right to revoke this consent at any time by giving written notice to BROWNSTONE PSYCHIATRY.

    I UNDERSTAND THAT REQUESTED COPIES WILL BE SUBJECT TO A REASONABLE FEE AS PROVIDED BY STATE LAW. ALL FEES WILL BE ON A PRE-PAY BASIS.

    I understand that I may not withdraw authorization for a disclosure that is necessary for the purpose of making payment to the facility for services provided. I understand that federal law and regulations protect the confidentiality of alcohol a drug abuse patient records maintained by BROWNSTONE PSYCHIATRY. Generally, we may not say to a person outside the facility that a patient is in treatment or disclose any information identifying a patient as an alcohol or drug abuse unless:

    1. The patient consents in writing by signing an authorization for the disclosure of information
    2. The disclosure is allowed by court order
    3. The disclosure is made to medical personnel in a medical emergency or to a qualified personnel for research, audit or
    4. Program evaluation. (42 CFR, chapter 1 part 2)
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