Authorization for Release of Protected Health Information Form

Authorization for Release of Protected Health Information Form
Date*

MonthDayYear
Date
Name of Patient*

First NameLast Name
Name of Releasee / Personal Information Controller*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I, the above-names Releasor, hereby authorize the release of the selected option for the purpose of Continuity of Care:*

All my health informationAll medical records related to lab results, drug screens, Genesight testing, behavioral health and medications.My Health information related to;
Health information
Please provide details what kind of health information shall be shared or disclosed and/or the date period
By signing this document, I hereby declare that I understand and acknowledge that I am giving authorization to the use and/or disclosure of my protected health information as described and for the purpose specified above.

I understand that my records are protected by federal regulations governing confidentiality of Alcohol and Drug Abuse patient Records, 42CFR, part 2 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that actions have been taken in reliance on it. and that in any event this consent expires automaticlly as follows:

This authorization shall remain effective from the time of execution of this document until:
Date or Event
Provide a date, instance, or event that this authorization shall cease to be effective
I am signing this authorization voluntarily. I understand that I have the right to withdraw my permission or withdraw my authorization at any time by writing. In case I withdraw my authorization, I understand that any benefits, treatment, or eligibility shall not be affected.

Further, I understand that this authorization may not further be used by the person or entity to whom my medical records are to be disclosed, to use or disclose the said information to another unless otherwise permitted in writing or unless such intended disclosure is required or permitted by law.

This information may be sent to A New Crossroad via:

Fax: 864-269-7948

Mail: 206 Wall Street Piedmont, SC 29673
Name of Patient/Representative*

First NameLast Name
Signature*

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Date Signed*

MonthDayYear
Date
Relation to Patient (if Releasor is not the Patient)*
Upload Proof of Identity

Cancelof
Type of Identification
Identification Number
Should be Empty: