Carolina Wellness & Recovery ROI

Carolina Wellness & Recovery

CONSENT FOR RELEASE OF INFORMATION
Powdersville

103 CLAIR DRIVE SUITE C, PIEDMONT, SC 29673

P: (864) 509-1337 F: (864) 416-4799
Greer

52 PARKWAY COMMONS WAY, GREER, SC 29650

P: (864) 655-4350 F: (864) 416-4799
PATIENT INFORMATION:
PATIENT NAME*

First NameLast Name
PATIENT DATE OF BIRTH*

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Date
LAST FOUR DIGITS OF YOUR SSN*
RELEASE/REQUEST MY TREATMENT RECORDS TO OR FROM THE FOLLOWING:
NAME AND LOCATION OF PERSON/ORGANIZATION TO RECEIVE OR DISCLOSE INFORMATION*
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Email
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THE FOLLOWING INFORMATION:*

ALLAPPOINTMENT INFORMATIONBILLING INFORMATIONPRESCRIPTION INFORMATIONLABWORKOTHER (if other, please specify in the text field directly below this section)
OTHER (please specify):
THE PURPOSE OF THIS DISCLOSURE IS:*
COORDINATION OF CARE /
EFFECTIVE PERIOD OF THIS RELEASE OF INFORMATION:*

Until I revoke it (verbal or written revocation accepted)Until The Date I Specify Below
LAST DATE OF EFFECTIVITY:

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CONFIDENTIALITY NOTICE:
I understand that my records, including any related to substance use disorder treatment, are protected under federal regulations, including the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR Part 2, which governs the confidentiality of substance use disorder records. These records cannot be disclosed without my written consent unless otherwise permitted by law. I also understand that I may revoke this consent at any time, verbally or in writing, except to the extent that action has already been taken in reliance on it.
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Carolina Wellness & Recovery

PATIENT INFORMATION:

RELEASE/REQUEST MY TREATMENT RECORDS TO OR FROM THE FOLLOWING: