Authorization for Release of Protected Health Information

*A specific name or a permitted class of recipients is required. If records are sent to you, enter your own contact information.

I authorize the above-named healthcare provider to disclose the requested medical information to the organization/individual named on this request. I understand that my medical records are protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended, and its implementing regulations at 45 CFR parts 160 and 164. Substance use disorder records subject to 42 CFR part 2 are also protected by that regulation, as amended by the final rule published February 16, 2024. These records may be used or disclosed with my written consent or as otherwise permitted or required by applicable law.I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions. I understand that I may revoke this authorization at any time upon written notice to Pillars Health Group, Attn: Medical Records, 1 Highwood Drive, Tewksbury, MA 01876, or by emailing the request to medicalrecords@pillarshg.com. I understand that revoking the form does not undo what was already provided before the ROI was revoked.This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosures are expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client. I understand I may see and obtain a copy of the information described on this form, and a reasonable copy fee may be charged. I understand that I may have a copy of the signed authorization form.