LOVE IN ACTION CDC (LIA) HEALTHY MINDS AUTHORIZATION FOR THE RELEASE OF CONFIDENTIAL INFORMATION

Name

Address

Date of Birth

Date

I Full Name do hereby authorize LOVE IN ACTION to release information contained in my patient records to the individuals or organization listed below:

1. Name and Address of Person s or organization(s) to whom disclosure is to be made:

I understand that my records (including any alcohol, drug abuse, or mental status information) are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except that action has been taken in reliance on it (e.g. probation, parole, etc.) and that in any event this consent expires automatically as described below. Prohibition on disclosure: This information has been disclosed to you from records whose confidentiality is protected by law. Federal regulations (42 C.F.R. Part 2) prohibits you from making any further disclosure of this infomation except with the specific written consent of the person to whom it pertains. A general authorization for the release of medical or othe information if held by another party is not sufficient for this purpose. Federalregulations state that any person who violates any provision of this law shall be fined not more than $500 in the case of a first offense and not more than $5000 in the case of each subsequent offense.

Drug abuse Office and Treatment Act of 1972 (21 USC 1175) comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (42 &SC4582), Federal Register, Vol. 40, 1 No. 127, July 1, 1975.

This release Authorization of for health the Release of Confidential Information shall become effective on the date of execution of my signature hereinafter, and this Authorization, which grants specific authority for the protected information by Early Start Behavioral Healthcare, shall remain valid until ____________upon which date this Authorization shall automatically expire. I retain the right to shorten, lengthen, or revoke this Authorization at any time by providing a written notice to Early Start Behavioral Healthcare, but I understand and agree that my consent to release information shall remain in effect until the revocation is date stamped in by the Medical Records Department, and any documents released previous to that date are considered to be authorized and approved by me.

Printed Name Client

Printed Name of LIA Representative

Signature of Client

Date

Signature of LIA Representative

Signature of Parent / Guardian

Signature of Parent/Guardian Date Date 1585 Compton Rd. Mt. Healthy, OH 45231 (Phone): 513-541-0405 (FAX) 513-541-0413 (Email): support@weloveinaction.org

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