Access Counseling Services, LLC

AUTHORIZATION FOR RELEASE OF INFORMATION

By signing the form below, you are authorizing your client to have the following information released to Robin McKinney (OWF Adminstrator), Cheryl Branstutter (OWF Asst Administrator), John Rice (OWF President), Jeannine Anderson (OWF Nurse):

1) Diagnostic Assessment

2) Urine Screen/ Lab Results

3) Discharge Summary

4) Progress Notes

5) Treatment Plan

6) Consultation

7) Diagnoses and/or treatment for alcohol and/or drug abuse

* My refusal to sign this authorization will NOT affect my ability to obtain treatment, payment, or enrollment in the health plan. This authorization will remain in effect for One Year.

NOTE:"This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules (ORC 5122.31, 42 CFR Part 2, and/or ORC 3701.243) prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client."

I understand that I have the right to revoke this authorization, at any time by submitting a written request to revoke authorization, and that the revocation will be effective except to the extent that Access Counseling Services, LLC has already taken action in reliance on my authorization.