I, First Name Last Name , born on Date , social security number, 000-00-0000 , authorize Recovery Management Services to:
I understand that the provider will not condition treatment, payment, enrollment, or eligibility on client's authorization for the release of information.
I understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the rules and regulations. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS), and/or related conditions.
I understand that I may revoke this authorization at any time upon written notice to Recovery Management Services. I acknowledge that such revocation will not be effective if Recovery Management Services has already acted in reliance upon this authorization.
This authorization is valid (if not previously revoked) this consent will terminate upon one year from the date of signature of this form, or the following date/event/condition: Date* , Event/ Condition or the completion of treatment, or at the time of the final insurance billing, as the case may be, whichever is later.
Prohibition on Re-disclosure
This information has been disclosed from records protected by Federal Confidentiality Rules (42 CFR part 2). The Federal rules prohibit 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. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.