Consent for Release of Information

Consent for Release of Information
Consent for Release of Information
Name*

First NameLast Name
Client Phone Number*
Please enter a valid phone number.
I authorize to disclose the following information:
Information to be released:

All of my substance use disorder records.Psychiatric/medical/alcohol/drug abuse evauation(s).Psychiatric/medical/alcohol/drug abuse discharge summaries.Progress NotesPsychological testing instruments/reportsPsychotherapy notesEducational testingLab Studies/ResultsMecical tests/studiesMedication(s) / DosingTreatment PlansToxicology ResultsSubstance Use HistoryDiagnostic informationTrauma history/assessments

Release to:

	Release Information to the following:
Organization
Attention to:
Address
State
City
Postal Code
Phone
Fax

Purpose For Disclosure*
I understand that my alcohol and/or drug abuse records are protected under federal regulations 42 C.F.R., Part 2 - Confidentiality of Alchol and Drug Abuse Patient Records and cannot be disclosed without my written consent. I may revoke this consent orally or in writing at any time. I understand that the revocation will not be effective retroactively for information disclosures that have already occurred.

If no date is included the Authorization will expire in 90 days.

- I understand that I may revoke this Authorization at any time, unless the Authorization was obtained as a condition of obtaining insurance coverage; that my revocation must be submitted in writing to the Facility/location where I originally
submitted/filed this authorization; and that the revocation shall be effective except to the extent that the Facility has already used or disclosed information in reliance on the Authorization.

- I further understand that treatment payment, enrollment in any health plan, or eligibility for benefits is not conditioned on signing this Authorization, however, Facility may condition the provision of health care that is solely for the purpose of creating protected health information for disclosure to a third party on my signing this Authorization, and Facility may condition the provision of research-related
treatment on my signing this Authorization.

- I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by applicable privacy law. I further understand that the facility, its employees, officers and agents are released from legal responsibility or liability for the use and disclosure of the above information to the extent indicated and authorized.

I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A COPY OF THIS FORM AND I AM THE PATIENT OR AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS DOCUMENT VERIFYING AUTHORIZATION FOR THE USE
OR DISCLOSURE OF THE PROTECTED HEALTH INFORMATION UNDER THE ABOVE STATED TERMS.
Date of Expiration of this Consent of Release of Information

MonthDayYear
Date
Signature (Use mouse to sign)

Clear
Signature Date

MonthDayYear
Date
If the individual is unable to sign due to legal incapacity, the signature of the individual's personal representative is required. Documentation of the personal representative's legal authority must be attached below.
File Upload

Cancelof
Signature of Personal Representative

Clear
Legal Authority
Date of Signature

MonthDayYear
Date
REVOCATION SECTION

By signing below, I am revoking this Consent for the Release of Information.
Signature of Client or Personal Representative (Use mouse to sign)

Clear
Date of Signature

MonthDayYear
Date
NOTICE TO RECIPIENT OF INFORMATION

This information has been disclosed to you from records protected by Federal confidentiality rules (42 C.F.R., Part 2). 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 information is not sufficient for this purpose (see Legal Text 2.31). The Federal rules restrict any use of information to criminally investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at Legal Text 2.12(c)(5) and 2.65.
TO PATIENTS OR LEGAL DESIGNEES:

FACTS ABOUT OBTAINING YOUR MEDICAL RECORDS:

You have the right to obtain a copy of your medical records. The law requires a signed authorization form which contains certain criteria included on this form. This form must be fully completed before any medical information can be
released. Incomplete forms may be returned for completion.

WHEN AND HOW WILL I GET MY RECORDS?

Requests will be completed within 30 days of receipt. You will be notified via mail if the records cannot be processed in 30 days. Records will be delivered as indicated on the request. If you are picking up your records, please note that they will only be held for 30 days once notice has been made that they are ready for pick-up. If they are not picked up within 30 days of the date of the notice, the copies will be destroyed and a new request will have to be completed. Please include your phone number so that we may call you when the records are ready for pick-up.
Should be Empty: