CONSENT TO COMMUNICATE PROTECTED
HEALTH INFORMATION TO AN AUTHORIZED PERSON
I give permission for United Health Centers to VERBALLY share the information I have described below to be released to the persons I have identified below. This form does not authorize releasing copies of my medical records.
*I understand that my records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient records, 42 CFR Part 2 and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 CFR Parts 160 & 164 and state confidentiality law governing behavioral health/substance abuse services (GS 122C)
cannot be disclosed without my written consent unless otherwise provided or in the regulations. I understand that the information to be released may contain information regarding alcohol abuse, drug abuse, HIV infection, AIDS or AIDS related conditions, psychological, psychiatric or physical limitations.
I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it. I understand that UHC may not condition my treatment based on the signature of this form.