Authorization to Release Confidential Information 2.0

Client Name*
DOB*
I, Client/Guardian* hereby authorize Groundwork Healing, LLC, 12 Stillwater Ave Suite 7 Bangor, ME 04401
To RECEIVE the following information: (Please check the appropriate box(es))*

DemographicsAssessmentProgress NotesTreatment PlanDischarge SummaryDISCLOSE ONLYOther
To DISCLOSE the following information: (Please check the appropriate box(es))*

DemographicsAssessmentProgress NotesTreatment PlanDischarge SummaryRECEIVE ONLYOther
Information to be RECEIVED FROM/DISCLOSED TO:
Name*
Relationship to client*
Address*
The purpose of this release is:*

Coordination of servicesLegal purposesObtain RecordsISP/ITP planningDetermine eligibility for servicesOther
Authorize release of any information that may relate to mental health treatment.*

I DOI DO NOT
Authorize release of any information that may be covered by federal rules relating to the confidentiality of alcohol or drug abuse treatment.*

I DOI DO NOT
Authorize release of any information that may relate to diagnosis/treatment for HIV, ARC, or AIDS.*

I DOI DO NOT
Unless earlier revoked, this will remain in effect until Date (Maximum 1 year).
I authorize the above-named provider to make subsequent disclosures to the same recipient pursuant to this authorization. I understand that the above information may be covered by the rules of the Maine Department of Behavioral and Developmental Services (the "Rights to Recipients of Mental Health Services" or the "Rights of Recipients of Mental Health Services Who Are Children in Need of Treatment")

I understand that I may refuse to release some or all of the information in the provider's records, but that such refusal may result in improper diagnosis or treatment, denial of coverage, or denial of a claim for health benefits or insurance, or other adverse consequences. The provider will not deny treatment on signing this authorization, unless the treatment is solely for the purpose of creating the information listed above for the person listed above.
Per company policy, Groundwork Healing, LLC will NOT release information created by other practitioners or facilities. Statements added to records by clients will not be released without written consent. I understand that if the above listed information is disclosed, it is possible that it may be redisclosed by the recipient, or that it may no longer be subject to confidentiality protections.
I approve Groundwork Healing, LLC to send these documents prior to me reviewing them:*

YesNo
I authorize the provider to send/receive these records by fax. Fax # (207)941-0880:*

YesNo
I acknowledge that I have been offered a copy of this authorization:*

YesNo
I understand that I may cross out any words on this form with which I disagree, and that I may revoke this authorization at any time.
Client*

Clear
Date

MonthDayYear
Date
Authorized Representative:*

Clear
Date

MonthDayYear
Date
Relationship to client
Witness:

Clear
Date

MonthDayYear
Date
***Request to Revoke***
I understand that I may revoke this authorization at any time by giving written or verbal notice to Groundwork Healing, LLC using this form or any other statement. This will not affect information released prior to receiving my request to revoke. I understand that revoking this authorization may be the basis for the denial of health benefits or insurance coverage benefits.

My signature below officially revokes this authorization:
Signature

Clear
Date

MonthDayYear
Date
Authorized Representative:

Clear
Date

MonthDayYear
Date
Relationship to client
Witness:

Clear
Date

MonthDayYear
Date
I understand that I must contact the office if I want my records sent out.
Check here to acknowledge
Should be Empty: