Release of Information (final)

Release of Information

Authorization for Release of Protected or Privileged Health Information
A. Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date of Birth
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Preferred Method of Communication*
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
B. Permission to Share

I give my permission to share my protected health information.
Records from:*
Send records to:*
Purpose: (check the appropriate box)*

Medical CarePersonal UseSchoolLegal ProceedingsInsuranceOther (specify below)
Other purpose
Send by:*
C. Information to be released: (check all that apply)*

History & PhysicalMedication List /HistoryDischarge SummaryVisit NotesLab Report(s)Diagnostic Test(s)Other (please specify below)
Other information to be released
D. Please check YES to indicate if you give permission to release the following information if present in your record:*

Yes Substance Use Disorder Treatment Records Protected by Federal Confidentiality Rules 42 CFR Part 2 (Federal rules prohibit any further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2.) This consent may be revoked upon oral or written request.Yes Details of Mental Health Diagnosis and/or Treatment provided by a Psychiatrist, Psychologist, Mental Health Clinical Nurse Specialist, or Licensed Mental Health Clinician (LMHC) (I understand that my permission may not be required to release my mental health records for payment purposes)Yes Alcohol and/or Drug Abuse TreatmentYes Confidential Communications with a Licensed Social WorkerYes Medication List / HistoryYes Drug Screening ResultsYes Psychiatric EvaluationYes Progress NotesYes Psychotherapy NotesYes Discharge Summary
Dates of Service to be Released*

Entire Medical RecordMost recent episode of carePrevious three monthsOther, please specify below
Other specified dates of service
e.g 3/2022-6/2024
Authorization Duration:

This authorization is valid for one year from the date signed unless otherwise specified below:
Date

MonthDayYear
E. Patient Acknowledgment and Consent

I understand and agree to the following:
1. I certify that I have read this authorization form in its entirety and fully understand its contents. I have had the opportunity to ask questions and seek clarification on any unclear points, and all my questions have been answered to my satisfaction.

2. I understand that Aspire Medical Group cannot control how the recipient uses or shares the information, and that laws protecting confidentiality at Aspire Medical Group may not apply once the information is released to the recipient.

3. I understand that this authorization is voluntary. My treatment, payment, health plan enrollment, or eligibility for benefits will not be affected if I do not sign this form.

4. I understand that I may revoke this authorization at any time by submitting a written request to the department or office where I originally submitted it. However, if Aspire Medical Group has already processed the request (e.g., once information is released, it cannot be retrieved), or if I signed this authorization as a condition of obtaining insurance, cancellation may not apply. Further release of information will cease, except as required by law, upon Aspire Medical Group's receipt of written revocation.

5. This authorization will automatically expire one year from the date signed, unless otherwise specified.

6. If Aspire Medical Group maintains any of my records from outside providers, these will not be released unless specifically requested. Please include the entity name, provider, and specific dates if known in the "Other" section (Section C).

7. By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

8. The parties acknowledge and agree that this consent agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.
Notice to Recipient of Protected Health Information:

Prohibition Against Re-Disclosure
- This information has been disclosed to you from records protected by federal confidentiality rules. 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 medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client.
- Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.
Age (years)*
Patient Name*

First NameLast Name
Patient Signature*

Clear
Date of Signature:*

MonthDayYear
Date
If the patient is a minor or is not legally competent to provide consent, the signature of a parent, guardian, or legal representative is required
Name (Parent, Guardian, or Legal Representative)

First NameLast Name
Signature of Parent, Guardian, or Legal Representative

Clear
Relationship to Patient (Parent, Guardian, or Legal Representative)
Date of Signature:

MonthDayYear
Date
Should be Empty:

Release of Information

A. Patient Information

B. Permission to Share

Authorization Duration:

E. Patient Acknowledgment and Consent

Notice to Recipient of Protected Health Information:

If the patient is a minor or is not legally competent to provide consent, the signature of a parent, guardian, or legal representative is required