Release of Information

Release of Information

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Discover Healing

512 91st Ave Ste C
Lake Stevens, WA, 98258

828 2nd St. Ste H
Mukilteo, WA, 98275
Discover Healing Clinicians may do the following with the below parties

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I authorize the release of any and all of the following medical or mental health information, as specified, which may be contained in my records. (Check all that apply, or check ALL, to agree to all options)*

ALLMedicationsPsychological EvaluationPsychiatric EvaluationDrug/ AlcoholMedical DiagnosisSchoolProgress NotesIntake EvaluationMedical HistoryTreatment PlanLaboratory ResultsDischarge Summary
The purpose of this disclosure (Check all that apply, or check ALL, to agree to all options)*

ALLITA Investigation/ CoordinationAssisting in Diagnosis and TreatmentAssuring Continuity of CareFacilitating Resident PlacementReporting to Probation Officer or CourtCoordinating Service DeliveryDetermine Program EligibilityEducating Family MembersReferring to Another Agency/ Person
Is there other purposes for this disclosure?
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I understand that my record may contain information regarding diagnosis or treatment of drug or alcohol abuse. I give my specific authorization for these records to be disclosed.(42 CFR, Part 2)

I understand that my records may contain information relating to mental health issues(per RCW 71.05.620). This authorization prohibits further use or disclosure of the information being released beyond the specific limits for this consent. I understand that information used or disclosed in keeping with this authorization may no longer be protected by Federal Law and could be used or re-disclosed by the receiving party. This consent is subject to my revocation at any time, except for information previously exchanged. To revoke this authorization, I must submit a written request to Discover Healing, DBA Discover Healing. I understand that I may refuse to sign this Authorization and that my refusal to sign may affect my ability to obtain treatment. Unless revoked earlier by me, this authorization shall expire either 30 days after the end of treatment or after all billing is complete whichever is later.
Signature of Client (If patient is 13 years of age or older, they must sign themselves)*

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Signature of 2nd Client if applicable

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Parent / Guardian Signature

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Release of Information

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