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Release of Information
Name
*
First Name
Last Name
School District
*
Please Select
Carroll
Floyd
Galax
Grayson
Patrick
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Name (if applicable)
First Name
Last Name
I hereby authorize the following to release protected health information to Tri-Area Community Health:
I hereby authorize Tri-Area Community Health to release my protected health information to the following:
Dates of service requested:
Information to be released:
History and Physical Exams
Immunizations
Lab Reports
Progress Notes
X-Rays or Diagnostic Imaging
Behavioral Health:
Mental Health/ Counseling Notes
Substance Abuse
HIV Related Information
Communication between counselors only
Dates of service requested:
Signature (Please sign if requesting Behavioral Health information)
Signature Date
-
Month
-
Day
Year
Date
Purpose of Release:
Please check all that apply:
Continuation/Coordination of Care, follow-up treatment or ongoing care
Changing Providers
Disability Determination/ Legal Needs
Second Opinion
Other
I understand this authorization will expire 1 year after I have signed this form.
I understand I may revoke the authorization at any time by notifying the providing organization in writing, and the revocation will be effective on the date notified except to the extent action has already been taken.
I understand that I am giving my permission to the above-named provider or other named third party for disclosure of confidential health care records. I further understand that TACH cannot condition the provision of treatment to me on my signing of this authorization.
A copy of this consent and a notation concerning the persons or agencies to which disclosure was made shall be included with my orginial records. The person who receives the records to which this consent pertains may not redisclose them to anyone else without my separate written consent unless the recipient is a provider who makes a disclosure permitted by law. There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipient and, therefore, no longer protected by the provisions of the HIPAA policy rule.
Signature
*
Signature Date
*
-
Month
-
Day
Year
Date
Relationship to patient (if applicable):
Continue
Should be Empty: