Authorization for Release of Information

1. I authorize*
Kenneth Young Center Staff Member
2. Check all that apply:*

to exchange withto receive fromto release to
3. Agency/Facility/Person:*
4. Phone Number & Address of Agency/Facility/Person:*
5. Assessment:*

PsychiatricMental HealthEducationalVocationalSubstance Use
6. Treatment Plan:*

PsychiatricMedicalSubstance UseIndividualized Treatment Plan
7. Other Information:*

Medical HistoryAdmission SummaryDischarge SummaryProgress NotesLegal (specify below)Other (Specify below)
8. If hospital records specify date of hospitalization:

MonthDayYear
Date
9. If Legal or Other please specify:
Patient Full Name:*
Patient date of birth:*

MonthDayYear
Date
For the purpose of:*

AssessmentRecords/Personal UseTreatment PlanningCoordination of CareOther
If you are requesting your records specify dates of treatment you are requesting:

MonthDayYear
Date
I understand this information may be transmitted via the following mode (please check all acceptable):*

WrittenVerbalElectronic
I understand that the above named agency/facility/person authorized to receive or exchange this information has the right to inspect and copy the information to be disclosed. I further understand that if the entity receiving this information is not a healthcare provider/plan covered by HIPAA privacy regulations, the information described above may be re-disclosed and longer protected by the HIPAA Regulations.

I understand that I may revoke this consent at anytime (revocation must be in writing). I understand that said revocation of this consent shall not be effective to prevent disclosure of records and communications until it is received by the person otherwise authorized to disclose records and communications.

It has been explained to me that if I refuse to the release, reception or exchange of information specified above the following are the consequences. *Specify consequences: INFORMATION WILL NOT BE DISCLOSED/OBTAINED
It is my full understanding that the records and communications to be disclosed WILL include sensitive information such as evaluation, habilitation/treatment information for mental health, developmental disabilities, alcohol or substance use/abuse or HIV/AIDs status. *CHECK BELOW FOR EXCLUSION ONLY*
Please check here for HIV/AIDS EXCLUSION if applicable

HIV/AIDS
*The Standards for Privacy of Personally Identifiable Health Information, 45 CFR parts 160 and 164, states that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of the information. The Federal Confidentiality Rules 42 CFR Part 2 prohibit making any further disclosure of drug or alcohol information unless further disclosure of this information is expressly permitted by the written consent of whom it pertains or as otherwise permitted by 42 CFR Part 2.
**Enter a FUTURE date below which is 1 year from date of signature. This is the date the form is no longer valid. Releases can be valid for up to 1 year unless you prefer a shorter duration – please specify the date this authorization will expire below**
I understand that this Authorization will expire on (one year from today's date):*
Not to exceed one year from today's date
Client Signature (required for ages 12 and older):

Clear
Parent of minor (17 and younger) OR guardian of disabled recipient:

Clear
Date:

MonthDayYear
Date
Should be Empty: