CDAC/WFIS Authorization for Release of Information

CDAC Behavioral Healthcare, Inc
CDAC/WFIS Authorization for Release of Information

Case Manager*

I,First Name* Last Name* consent to disclosure by CDAC Behavioral Healthcare / Women & Family Intervention Services (WFIS) Program of confidential information concerning my participation in the above mentioned program as follows:

1. Name of person, agency, title and relationship to the parent to or from whom disclosure is to be made:*

Name of entity

2. Specific information to be disclosed by CDAC or to CDAC (check all that apply):*

Presence in ProgramDemographic Information *may include name, address, and phone number.Recommendations for substance use interventionsProgress updates/feedback on engagement in services

Use Intervention Status information to include

Biopsychosocial history collected during intake process to include pattern of substance use andwithdrawal potential, biomedical conditions and current medications, treatment history, emotional/behavioralconditions and complications, readiness for change, relapse / continued use potential, recovery environmentstatus, contact with case manager, and progress on intervention plan.Discharge SummaryOther

3. Purpose or need for such disclosure*

Advocate in dependency caseCare CoordinationOther (please indicate specific purpose):

Please describe

I understand that my records maintained by this program are protected under the federal regulations governing Confidentiality of Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. 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, and that in any event this consent shall have a duration no longer than Number of months* months (Not to exceed twelve (12) months).
Dated this day* day of month* , 20 year*.
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I have been provided a copy of this form.

Date*

Date

Participant Signature*