• Authorization Form for Release of Medical Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • I hereby authorize Ground Up Behavioral Health, LLC to*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Please select all the specific documents that apply to your request*
  • I authorize the disclosure of the above information for the following purpose(s)*
  • Please release my medical records from the following treatment date range*
  • Start Date*
     - -
  • End Date*
     - -

  • Please fax any records released under this authorization to Ground Up Behavioral Health, LLC at 800-317-0547. If you have any questions regarding this authorization, please contact us at 334-746-5586.

  • Copies of medical records released to patients, attorneys, or other third parties may be subject to the following charges, as permitted by applicable law:

    Pages 1–25: $1.00 per page
    Pages over 25: $0.50 per page
    Search Fee: $5.00
    Mailing Fee: Actual cost of postage

    Records sent directly to another treating healthcare provider for continuity of care will be provided at no charge.

    You will be notified of the estimated total before your request is processed. All applicable fees must be paid before the records are released.

  • Authorization and Acknowledgment of Understanding

    1. I understand that this authorization, except for actions already taken, may be revoked by me in writing at any time by notifying the Site Administrator at Ground Up Behavioral Health.

    2. I understand that Ground Up Behavioral Health will not condition services, treatment, or payment on whether I sign this authorization.

    3. Unless I have specifically requested in writing that the disclosure be made in a certain format, I understand that the clinic reserves the right to disclose information permitted by this authorization in any manner deemed appropriate and consistent with applicable law, including but not limited to verbal, paper, or electronic formats.

    4. I understand that my health record may include information relating to behavioral or mental health treatment, alcohol and drug use, and other sensitive information. Further disclosure of this information is prohibited unless expressly permitted by my written consent or as otherwise required or authorized by law.

    5. I understand that my records are protected under federal law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164, and, where applicable, the Confidentiality of Substance Use Disorder Patient Records regulations (42 C.F.R. Part 2). These records cannot be disclosed without my written consent unless otherwise permitted by these regulations.

    6. This authorization permits the release of necessary information, including diagnosis, treatments, and examinations rendered to me during the specified period, for the purposes of continuity of care, improving assessment and treatment planning, sharing information relevant to treatment, and/or coordinating treatment services.

    7. I understand that records released to patients, attorneys, or third parties (such as disability services) may be subject to reasonable administrative fees.

    8. If this authorization is not revoked, it will expire ninety (90) days from the date of signature, unless otherwise specified in writing.

  • By signing this form, I authorize Ground Up Behavioral Health, LLC and the person or facility identified above, as applicable, to request and/or disclose my protected health information as described in this authorization.

  • Date Signed*
     - -
  • Should be Empty: