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:
Regarding (Client Name)

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Program/Person Authorized to Disclose/Receive/Exchange Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax #
Please enter a valid phone number.Format: (000) 000-0000.
Name of Program/Person Authorized to Receive/Disclose/Exchange Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Purpose of Disclosure- Select one
Information to be Disclosed
Other specified information
Amount of Information to be Disclosed
Other specified amount of information
I understand that, unless withdrawn, this authorization will expire 180 days from the date of signature. A photocopy of this form will be considered as valid as the original. I understand that I may revoke this authorization at any time by notifying Modern Mind Clinic, in writing, and this authorization will cease to be effective on the date notified except to the extent action has already been taken in reliance upon it.
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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: