Consent for Release of Information Form
Patient Name
*
Patient DOB
*
Who
I authorize my information to be released FROM Cedar Recovery TO
(name and how you know them)
Who
I authorize my information to be released TO Cedar Recovery FROM
(name and how you know them)
What: (check all that apply)
That I am a patient
Dates of Treatment
Labs
Medication list
Treatment status from therapist (letter)
Doctor notes
Assessments
Doctor recommendations (treatment plan)
Other
From Another Doctor or Person/Agency:
Complete Chart
Labs
Medication list
Outside therapist notes
Doctor Note
Doctor recommendations (treatment plan)
Other
Why: The information is being released for the following purpose:
As a letter directly to the patient for legal or personal purposes
For an open DCS case
To help my doctor plan my care with another doctor (care coordination)
Other
When, Where, and How
This release will expire one year from today unless I choose to take it back (revoke) before then. I can choose to take it back at any time and my information will not be released from that point forward. I can choose to take it back on any date or for any reason or event.
This release gives permission for my information to be exchanged either in writing (mailed, faxed, or securely emailed) or conversation (phone call).
I understand that choosing to not sign this form will not make a difference in being able to receive treatment at Cedar Recovery. I freely and voluntarily give my consent
I understand that federal and state laws protect my records, and they cannot be released without my consent unless another law requires them to be released.
I understand that once Cedar Recovery released my records to who I have given permission to, there is no assurance of privacy of the records from that point forward
Patient Signature
*
Date
*
/
Month
/
Day
Year
Date
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