HIPPA Release Form

Consent For Releasing And Obtaining Confidential Information

Document will be reviewed in it's entirety prior to submission
I or my authorized representative,*
(Enter Participant's Name)
authorize BRiDGES Council on Alcoholism/Employee Assistance Program to release to and/or obtain information from*
(Enter name of person or organization to which disclosure is to be made)
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996, (HIPAA), as follows: The described confidential information to be released:*
(Nature and amount of information to be disclosed: as limited as possible)
The described confidential information to be obtained:*
(Nature and amount of information to be disclosed as limited as possible)
The purpose of disclosure*
(As specific as possible)
I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulation. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:

When file is closed or one year from date release was signed.
I understand that generally BRiDGES Council on Alcoholism/Employee Assistance Program may not condition my treatment on whether I sign a consent form, but that in certain limited circumstances I may be denied treatment if I do not sign a consent form. I understand that signing this authorization is voluntary.
Dated*

MonthDayYear
Date
(Signature of Participant)*

Clear
Signature of parent, guardian, or authorized representative where required)

Clear
A PROGRAM OF THE MADISON COUNTY COUNCIL ON ALCOHOLISM AND SUBSTANCE ABUSE, INC.

PO Box 389 1507 Upper Lenox Ave.Oneida, NY 13421 TEL: (315) 697-3947
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Consent For Releasing And Obtaining Confidential Information