Authorization for Release of Confidential Information

  • Authorization for Release of Confidential Information

    Grandis Evaluation Center P.C.

  • This form is used to give permission to share information with individuals or agencies. If you would like for us to share information (ex. your report) with someone besides you, please fill out the form below. If you do not want us to share information with others, you do not need to complete this form. 

    This form implements the requirements for client consent to use and disclose information protected by the federal health privacy law (45 C.F.R. parts 160, 164), the federal drug and alcohol confidentiality law (42 C.F.R. part 2), HIV-AIDS (45 C.F.R. Parts 160 & 164) and state confidentiality law governing mental health, developmental disabilities, and substance abuse services (G.S. 122C).

  • Client Information

    *The person being assessed
  • Date of Birth
     - -

  • Authorization

  • I authorize:

    Grandis Evaluation Center P.C.
    1011 Tunnel Rd. Ste 220 Asheville NC 28805
    9121 Anson Way Ste 200 Raleigh NC 27615

    To disclose information to:

     

  • Information to be Released/Disclosed*
  • Optional - Sensitive Information (please check here if you would like the following information redacted from your shared information)
  • Purpose of Disclosure

  • This authorization will expire on .
    *If not specified, this authorization will expire one year from the date of signature.

  •  

    Client Rights and Understanding:

    • I understand that I may revoke this authorization at any time by submitting a written request.
    • I understand that signing this authorization is voluntary, and my treatment, payment, enrollment, or eligibility for benefits is not conditioned on signing (except where permitted by law).
    • I understand that I am entitled to receive a copy of this authorization.
  • Date*
     - -
  • Should be Empty: