• Consent for STAR CENTER, Inc. to Disclose Confidential Medical Information


    The purpose of this consent is to exchange and discuss information and treatment to coordinate care.


    I authorize Star Center, Inc., its physicians, nurses, and counseling staff to release and exchange information to my Primary Care Physician or Behavioral Health Provider.

    • The following information will be released: medication, dose, drug test results and any other information deemednecessary to coordinate care and ensure patient safety.
    • I also allow the physicians at Star Center to verbally discuss my treatment with my primary doctor or behavioral health care team.
    • I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, as well as the HIPAA Act 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 to the extent that action has been taken in reliance on it, and that this consent automatically expires after one year.
  • DOB:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • I decline to coordinate care with my Primary Care Physician and/or Behavioral Health Provider
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • The above-named patient is currently enrolled in treatment at our facility. This treatment entails daily dispensing of Methadone * mg, and regular counseling sessions.

  • Date of last Visit:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Next Visit:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Rows
  • Treating Physician Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: