New Authorization for the Release of Protected Health Information

Authorization for the Release of Protected Health Information
Client Full Name*

FirstMiddle NameLast Name
Client Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I First Name* Last Name* , hereby authorize Aaran Therapy Center to:
(check all that apply)
Receive information from
Provide information to
Exchange information with*

I understand that:
- My health information is protected by federal regulation (Alcohol and Drug Abuse Patient Records, 42 CFR Part 2: and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Aaran Therapy Center, Inc. Privacy Notice. I understand that I have a right to inspect and receive a copy of my treatment records that may be disclosed to others, as provided under applicable state and federal laws.
- I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Aaran Therapy Center, Inc. Privacy Notice outlines the procedure for revocation. This authorization will expire in one year from the date I sign or unless I request an earlier expiration by entering a desired date below.
- For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) (45 CFR & 164.508 (b)(4)(III)
- Communications resulting from this authorization will reveal that I receive services at Aaran Therapy Center, Inc.
- Federal confidentiality regulations (at 42 CFR Part 2) prohibit re-disclosure of information from alcohol and drug abuse patient records. However, HIPAA requires Aaran Therapy Center, Inc. notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules.
- This authorization may be used by Aaran Therapy Center, Inc. owned or managed programs upon transfer of my care to them.
- This information is confidential and will only be used for business purposes and then shredded after 7 years as regulated by HIPAA/confidentiality laws below:
If you prefer the authorization to expire in less than one year from the date you sign this form, please specify your preferred expiration date below.
Client or Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Client or Parent/Guardian Printed Name*

First NameLast Name
Staff/Witness Signature if applicable

Clear
Date

MonthDayYear
Date
** Information to be disclosed to you from records protected by Federal confidentiality rules (42 CFR 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 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
Should be Empty: