Release of Information

What is this Release of Information (ROI) being used for today?

Insurance verificationRequesting records from another provider (incoming)Sending records to another provider (outgoing)Coordination of careAdmission coordination for care coordinationOther
Are you currently working with someone at Recovering Hope regarding this request?

YesNo
If yes, who are you working with? (Receptionist, provider, admissions team, etc.)
Authorization To Release Protected Health Information
Client Information
Full Legal Name*
Date of Birth *

MonthDayYear
Date
SSN*
Email
Phone Number*
Please enter a valid phone number.
Address*

Address

Street Address Line 2

CityState

Zip Code
Disclosure of Authorization
I hereby authorize Recovering Hope Treatment Center, Located at 2031 Rowland Rd, Mora Mn 55051 to (select all that apply)*

Obtain InformationRelease InformationExchange Information
WITH ( (Provide the name of the organization or individual you are authorizing us to share information with)
Name / Organization *
Address
Phone Number
Please enter a valid phone number.
Email
example@example.com
Disclosure Disclaimer – Please Read Before Selecting

Important:
Substance Use Disorder (SUD) information is protected by federal law (42 CFR Part 2). We will only release the specific information you authorize us to share.

If you select "Other," please be very specific and brief about what you would like released. Vague requests may delay processing, and overly broad authorizations may not be honored.

Our goal is to protect your privacy-please take care in selecting and describing what you wish to share.
Please select ALL Information you are disclosing.
Substance Use Records

Comprehensive Substance Use AssessmentIndividual Treatment Plan for Substance UseWeekly Treatement Plan for Substance UuseDischarge Summary for Substance UseOther
Please describe the other specific information you want shared:
Medical Records

Medication ListComprehensive Medical AssessmentUA and LabsMedical Progress NotesOther
Please describe the other specific information you want shared:
Mental Health Records

MH Diagnostic AssessmentMH Individual Treatment PlanMH Discharge SummaryPsychological TestingOther
Please describe the other specific information you want shared:
Other

Acknowledgment that the client is receiving servicesFinancial, Insurance & Funding InfoEmergency ContactAll Child InformationPermission to pick up client belongingsOtherOther
Please describe the other specific information you want shared:
Please describe the other specific information you want shared:
Purpose for Disclosure
Select ALL that apply

ReferralCase ManagamentCare CoordinationConsultationCollateral ContactAt the request of the clientOther
Please describe the other specific information you want shared:
Methods of Disclosure
Select ALL that apply

VerballyIn PersonWrittenMailed or faxed
Do you want to limit the dates of service for this release of information?

No, I authorize the release of protected information for all dates of serviceYes, I want to specify a limited date range
I authorize the release of protected health information for all dates of service.**If you would like to limit the time frame, please indicate it below.

Important:
If you choose to limit the date range for this release, please ensure the dates are accurate.

If the service date falls outside of the authorized time frame, we will not be able to release that information without a new or updated release form.

Inaccurate or incomplete dates may cause delays in processing or sharing your information with third parties.
Start Date of Authorized Services:

MonthDayYear
Date
End Date of Authorized Services:

MonthDayYear
Date
I understand that:
- My health information is protected by federal regulations — including 42 CFR Part 2 (Alcohol and Drug Abuse Patient Records) and 45 CFR (HIPAA) — as well as
  applicable state privacy laws. Disclosure is permitted only with my written authorization, except in limited circumstances described in Recovering Hope Treatment
  Center’s Privacy Notice. I have the right to inspect and receive a copy of my treatment records in accordance with applicable laws.
- I may revoke this authorization at any time, except to the extent that action has already been taken in reliance on it. The procedure for revocation is outlined in
  Recovering Hope Treatment Center’s Privacy Notice. Unless otherwise specified in writing, this authorization will expire one year from the date it is signed, or earlier
  if requested in writing.
- For disclosures other than those made for treatment, payment, or healthcare operations, Recovering Hope Treatment Center may not condition my treatment on
  signing this authorization — unless I am receiving services solely for the purpose of creating information to be disclosed to a third party. (45 CFR § 164.508(b)(4)(iii))
- Communications resulting from this authorization may reveal that I receive services at Recovering Hope Treatment Center. Federal confidentiality rules (42 CFR Part
  2) prohibit the re-disclosure of any substance use disorder (SUD) information. However, I understand that HIPAA requires Recovering Hope to inform me that
  information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA.
- This authorization may also be used by other Recovering Hope-owned or managed programs if I transfer care to those programs.
- All disclosed information will be treated as confidential and will only be used for business and treatment coordination purposes. Records will be retained as required
  and securely destroyed after seven (7) years, in compliance with HIPAA and 42 CFR Part 2.
- Notice to recipient: Information disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2) must not be further disclosed unless expressly
  permitted by the written consent of the individual to whom it pertains or as otherwise allowed by law. A general authorization is not sufficient for this purpose. These
  rules also prohibit the use of disclosed information to criminally investigate or prosecute any alcohol or drug abuse patient.
Signature Disclaimer:
By signing this form, I confirm that I am the individual whose information is being released, or that I am legally authorized to act on their behalf (such as a parent of a minor or a court-appointed legal guardian).

I understand that signing this form without legal authority may result in legal consequences, including but not limited to investigation for fraud or misuse of identity.
Who is completing and signing this form? Please select the option that best describes your role in completing this form:

I am the client and able to sign for myselfI am the parent or legal guardian signing on behalf of a minor client (under age 18)I have legal authority to act on the client’s behalf (legal guardian, conservator with medical authority, or holder of healthcare power of attorney).
Client Signature required

Clear
Date

MonthDayYear
Date
ONLY If applicable: Signature of Witness / Guardian / Third Party

Clear
Name

First NameLast Name
Today's Date

MonthDayYear
Date
If you are signing this form on behalf of the client,
Please upload documentation showing your legal authority to do so (e.g., court order, guardianship papers, healthcare POA).

Forms signed without proper legal documentation may be rejected or delayed.
File Upload

Cancelof
Should be Empty:

Authorization To Release Protected Health Information

Client Information

Disclosure of Authorization

Please select ALL Information you are disclosing.

Purpose for Disclosure

Methods of Disclosure