Release of Information Consent Form

I AUTHORIZE:

Balance Point Health Services

3650 Muddy Creek Rd Cincinnati, OH 45238

Phone: 513-347-0375 Fax: 513-347-0376

 

To:

release information, obtain information, and exchange information with the person/organization in PART 1.

I UNDERSTAND THAT:

• My health information is protected by federal regulation (Alcohol & Drug Abuse Client Records, 42 CFR Part 2; and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Balance Point Health Services Privacy Notice.
• My refusal to sign this authorization will NOT affect my ability to obtain treatment. However, I understand that I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Balance Point Health Services' Privacy Notice outlines the procedure for revocation. This authorization will expire in one year from the date I sign or unless I request an earlier expiration in writing.
• NOTE: This information has been disclosed to you from records whose confidentiality is protected from disclosure by State and Federal law. ORC 5122.31. 42 CFR Part 2, and/or ORC 3701.243 prohibit you from making any further disclosure of it without the specific and informed release of the individual to whom it pertains, their authorized representative, or as otherwise permitted by law. A general authorization for the release of information is NOT sufficient for this purpose.
• Communications resulting from this authorization will reveal that I receive services at Balance Point Health Services.
• Federal confidentiality regulations (42 CFR Part 2) prohibit re-disclosure of information from alcohol & drug abuse Client records. However, HIPAA requires Balance Point Health Services to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA.