Authorization for Release of Information

Authorization for Release of Information

Please read the entire form before signing below.
ATTENTION: We will not release your information to anybody unless legally obligated. Please list anyone who will need access to your record (emergency contact, probation/parole officer, PCP, etc.)

You must list the EXACT NAME of who you want the information to be released. "Parole Officer", "DCBS" will not be accepted and no information will be released unless your specific Parole Officer's name or caseworker's name is listed, for example.
I,First Name* Last Name*, give my authorization for CommonHealth Recovery, located at 1121 Louisville Rd. STE 501, Frankfort KY 40601 to request/release the information identified below from/to Name(s) of Individual or organization(s)*.
List the specific information which is to be requested/released:*

Patient's Medical FileOther
I am authorizing this request/release for the purpose of:*

Medical TreatmentOther
I am giving my consent voluntarily and understand that delivery of service does not depend on authorization being given. This authorization will continue for the duration of treatment unless stated specifically. I understand that I may revoke this authorization at any time by signing below. The above-named agency cannot be responsible for releases of information prior to permission being revoked or as required by law.

Prohibition on re-disclosure: Once the information is released, it is outside the control of the agency relating the information, however, both Kentucky and federal law offer protections that mental health and chemical dependency information may not be re-disclosed without the specific written consent of the person identified in the information.
Client Name*

First NameLast Name
Client Date of Birth (DOB)*

MonthDayYear
Date
Client Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty: