Authorization for Access, Release and Use of Medical Information

Date:

This release will expire one year from today's date.

Contact Name:

First NameLast Name

Contact Email Address:

example@example.com

Client Name:

First NameLast Name

Date of Birth:

The person named above is or has been a client of A Chance to Grow, Inc. (hereafter referred to as ACTG). ACTG is required to keep personal information, identifying information, and records confidential. By signing below, clients allow ACTG to access, send, and/or use information from your medical provider.

Medical Release:

I hereby authorize ACTG to:

Request health information fromSend health information toDiscuss health information with (provide Clinic/Primary Physician details below):I do not authorize ACTG to request, send, or share my health information at this time.

Clinic/Primary Physician:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Fax Number:

Scope of information to be released:

All information regarding assessment, diagnosis, and treatmentOther (please specify below)

Other information to be released:

If applicable and pertains to direct treatment:
The following information requires specific authorization due to additional release protection. To authorize release or discussion of the following type of information with your provider, you must initial and date each item. If an item is not initialized and dated, the information, if such exists, cannot be released or discussed.

Initial   Date   Alcohol Use / Abuse Treatment
Initial   Date   Drug Use / Abuse Treatment
Initial   Date   Mental Health Treatment
Initial   Date   HIV Status or Treatment

Please initial the following:

Initial   I understand that this authorization is effective for the above requested and authorized health care information only.
Initial   I understand that I have the right to inspect the information I am authorizing to be re-released. This and other specific rights regarding the handling of your health information are outlined in our privacy practices document.
Initial   I understand I do not have to allow A Chance To Grow, Inc. to share my information and that signing a release form is completely voluntary. My refusal to sign this authorization will not affect my ability to obtain treatment except to the extent that the information being requested may assist ACTG in determining appropriate treatment.
Initial   I understand that if I would like A Chance To Grow, Inc. to release information about in the future, I will need to sign another written, time-limited release. This release is limited to the information contained in this document.
Initial   I understand that my information may be shared in person, by phone, fax, mail, or email. I understand that email is not confidential and can be intercepted and read by other people. Releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from ACTG.
Initial   I understand that I may withdraw my consent to this release at any time in writing. ACTG may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share with others.
Initial   I understand that records created by and available from other providers, hospitals, or other care facilities must be obtained directly from those other providers or facilities.

Authorization:

Name:

First NameLast Name

Client or Guardian Signature:

Date:

If not signed by client, indicate relationship of authorizing representative to client: