> If yes, please have ther consumer sign a Relase of Information allowing Managed Care organizations to receive the information on this referral and to share information with RI International's IRT Team

> If not, please obtain consent prior to submitting this form.

Referral Checklist: Please include all necessary and listed documentations with referral form.

Emerald City Behavioral Health
Address: 3713 Pacific Ave, Tacoma, WA 98418 Phone: 253-433-7993 Fax: 253-540-6886

I hereby authorize Emerald City Behavioral Health to release and exchange information regarding my mental health and substance use treatment records with the following individual or organization:

I understand that my treatment records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that once information is disclosed, it may be re-disclosed by the recipient and may no longer be
protected by federal or state law.

If the client is unable to sign, please indicate the legal representative's information: