Release of Information

Provider Name:*

Fax

Address

Student Name*

Date of Birth*

PLEASE RETURN FORM TO: ATTENTION*

Return this form to who?

INFORMATION TO BE RELEASED / REQUESTED FOR THE FOLLOWING PURPOSE:

TreatmentLegal RequestInsurance ClaimOther:

Please check specific information to be released:

This information may be used for continuation of care. I understand this authorization will expire on Date* and / or 6 months following the date of discharge from any AK Child & Family, revocation of custody or guardianship, or upon written revocation,
whichever comes first. This authorization may be revoked prior to the
expiration, but not retroactively. Photo static and / or facsimile
copies of this authorization will be considered as valid as the
original.

PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR part 2) prohibit you from making any further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for the release of medical or other information if held by another party is not sufficient for this purpose. Federal regulations restrict any use of this information to investigate or prosecute any alcohol or drug abuse patient. Disclosure of patient information is permitted with the patient’s written consent: however, disclosures to central registries and in connection with criminal justice referrals must meet the following specific regulations: (42 CFR 2.32 and 2.33 This information disseminated from AK Child & Family.

I acknowledge that the information to be released is protected by Federal law and may include information regarding drug / alcohol abuse, sexually transmitted diseases / HIV and / or Hepatitis B. My signature below authorizes the release of this information. I understand that authorizing the disclosure of the above information is voluntary and I need not sign this form to ensure treatment. I understand that once the above information is disclosed, it may be subject to re-disclosure by the recipient and no longer protected by federal privacy laws or regulations.

Student signature

Student signature Date

Parent / Guardian Signature*

Parent / Guardian signature Date*

Witness Signature

Witness signature Date

Please verify that you are human*

Authorization for Exchange of Information

I hereby authorize AK Child & Family to exchange personal health information between AK Child & Family and:

for:

AK Child & Family • 4600 Abbott Road Anchorage, AK 99507 • (907) 346-2101 • Fax (907) 348-9230