Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information [3793:2-1-06(H)]
As noted below the following are authorized to (select all that apply):

Release InformationReceive Information
Regarding (Patient Name)

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Second Party: Authorized to Release/Receive Information
Name of Provider, group, agency
Second Party Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax #
Please enter a valid phone number.
Purpose of Disclosure- Select one

Continuity of CareDisability DeterminationOngoing TreatmentTreatment PlanningCollateralOther, please specify below
Other specified information
Information to be Disclosed

All recordsAttendanceCrisis AssessmentHIV/AIDS tests/resultsLab tests including medication resultsPhysician's Orders/Medical NotesPregnancy Test resultsPrenatal Care ReceivedProgress in TreatmentPsychiatric EvaluationPsychological EvaluationInformation on Mental Illness and /or TreatmentUrine TestingOther, please specify below
Other specified information
Amount of Information to be Disclosed

All RecordsMost recent episode of careOther, specify
Other specified amount of information
I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon receipt of the written revocation.
Signature
Date signed

MonthDayYear
Date
NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.
Should be Empty: