Release of Information

Release of Information
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Client phone
Please enter a valid phone number.
Client email
Is the client unable to sign for themselves and has a legal representative?*

YesNo
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV),mental health and substance use.
I authorize the release or disclosure of the Substance Use Disorder/Mental Health records below:*

All my substance use disorder records. By selecting option, I understand that these records include al the types of records below.Toxicology Results/Urine Drug Screen ResultsAppointmentsMedication(s)AssessmentProgress in treatmentTreatment PlanInsurance Information/DemographicsDiagnostic InformationDischarge SummarySubstance Use HistoryTrauma HistoryOther
What purpose are you authorizing the release of your information for?

Care, Treatment, and ServicesReferralsLegal/Court Ordered ServicesOther
Entity disclosing my records:

I authorize Lefkowich Counseling and my provider(s) of record to disclose my records in accordance with this Consent and Authorization.
My information may be released to (enter organization or individual's name)*
Organization's Phone Number
Organization's Fax Number
Organization/Individual's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Federal and state laws protect the privacy of my records:

I, the above-named client, understand that my substance use disorder records are protected under federal law (including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164) and state law (including the Minnesota Health Records Act, Minn. Stat. §§ 144.291-34), and cannot be disclosed without my written consent unless otherwise provided for by law.
The purpose of this Consent and Authorization for the Release of Substance Use Disorder Treatment Information (this “Consent and Authorization) is to give my written consent to the disclosure of some or all of the records relating to my substance use disorder treatment. I understand that my records, once released pursuant to this Consent and Authorization, may no longer be protected by the above-mentioned federal and state laws.

Revocation and expiration:

I understand that I may revoke this Consent and Authorization at any time by notifying Lefkowich Counseling LLC in writing. I further understand that any such revocation will not apply to disclosure made in reliance on this Consent and Authorization before Lefkowich Counseling LLC received my written notice of revocation.
Unless earlier revoked by me, this Consent and Authorization will expire one (1) year from the date it is signed by me unless earlier revoked by me.
I understand that, upon my request, YourPath will give me a copy of this Consent and Authorization.
Date of Client Signing*

MonthDayYear
Date
Client Signature*

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