(Updated) Release of Information

Consent for Release of Information
Completion of this document authorizes the disclosure and/or use of health information, about you. Failure to provide all information requested may invalidate this Authorization.
I HEREBY AUTHORIZE

North American Mental Health ServicesOther
Persons/Organizations authorized to release the information requested
Persons/Organizations Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Persons/Organizations Phone Number

Area CodePhone Number
Persons/Organizations Fax Number

Area CodePhone Number
TO DISCLOSE TO:

MyselfOther
Persons/Organizations authorized to receive the information
Persons/Organizations Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Persons/Organizations Phone Number

Area CodePhone Number
Persons/Organizations Fax Number

Area CodePhone Number
THE FOLLOWING INFORMATION:

A. All health information pertaining to my medical history, mental or physical condition, treatment, medications, results of lab test or image studies.(Excluding Therapy Notes)
Date Range (From)

MonthDayYear
Date
Date Range (To)

MonthDayYear
Date
B. Only the following records or types of health information (including any dates):
Please choose which specific information you want your provider to share.

A copy of your Medication Management Progress NotesA copy of your Therapy NotesList of current medicationsResults of a lab test or diagnostic studiesClinical SummaryA copy of your substance abuse recordsOther
Date Range (From)

MonthDayYear
Date
Date Range (To)

MonthDayYear
Date
DELIVERY FORMAT: I would like this information released via the following methods:

FaxMailIn-Person Pick-UpPatient Portal
PURPOSE: Purpose of requested use or disclosure:

Patient Personal RequestOther
Limitations if Any:
MY RIGHTS:
- I may refuse to sign this Authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits.
- I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of.
- I may revoke this authorization at any time, but I must do so in writing (Revocation of ROI Form) and submit to the Medical Records Department (2400 Washington Ave. Suite 100, Redding CA 96001) or online via the NAMHS website. My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization.
- I have a right to receive a copy of this authorization. Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such re-disclosure is in some cases not prohibited by California law and may no longer be protected by federal confidentiality law (HIPAA). However, California law prohibits the person receiving my health information from making further disclosure of it unless another authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law.
ACKNOWLEDGEMENT:
This authorization will remain valid for one year from the date of signing unless an alternate expiration date is provided here: Date .

I have read and understand this consent form, and I agree to its terms.
Patient Name:*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Signature*

Clear
Date

MonthDayYear
Date
Guardian/Legal Representative Name

First NameLast Name
Date

MonthDayYear
Date
Guardian/Legal Representative Signature

Clear
Should be Empty:

Consent for Release of Information