Release Form

Release Form
Authorization for Use & Disclosure of Protected Information

This form is to allow us to disclose/share information with persons or agencies with your permission.

Fill out the requested information below, and click "submit" to submit the form. You will be prompted to e-sign and be given the opportunity to download the form as a PDF. It will be emailed to you as well.

Your information is completely secure and encrypted in full compliance with HIPAA's regulations regarding ePHI (electronic Protected Health Information).
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Insurance Information
Policy Holder
Insurance Provider (Please select primary)

MedcaidBlue Cross / Blue ShieldOther
Understand that you may refuse to sign this form and that services cannot be denied based on your refusal to sign. 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).
Authorization Info
Person filling out this form

First NameLast Name
I hereby authorize the name of the person or agency listed below:
(Note: NOT your name, but rather the person or agency to share information with)
To Disclose and/or Share Protected Health Information with:
Grandis Evaluation Center, PC
Protected Information to be Used/Disclosed *

Evaluation(s)Substance Abuse InformationHIV informationProgress NotesOther
E-Signature

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Release Form

Authorization for Use & Disclosure of Protected Information

Client Information

Insurance Information

Authorization Info