Release of Information Form

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information [3793:2-1-06(H)]. This form cannot be used for the re-release of confidential information provided to The Caring Collective LLC by other individuals or agencies. Such requests should be referred to the original individual or agency.
This form is to authorize The Caring Collective LLC to obtain and/or disclose information as specified below.

Mail: PO Box 145, Berlin Heights, Ohio 44814 Phone: 419-515-6865 Fax: 419-938-1077
The Caring Collective LLC is granted permission to*

Disclose InformationReceive InformationExchange Information
Client's Legal Name*

PrefixFirst NameMiddle InitialLast NameSuffix
Date of Birth*

MonthDayYear
Person or Organization with Whom Information can be Shared*
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax #
Please enter a valid phone number.
Purpose of Disclosure

Coordinating On-Going Treatment Efforts/Continuity of CareFamily/Caregiver/Significant Other InvolvementScheduling/Coordinating AppointmentsEvaluation/Assessment Coordination504 Plan/IEP CoordinationSafety PlanningDetermining Eligibility for Benefits/ProgramOther
Information to be Disclosed

Intake/Diagnostic AssessmentScheduled Appointments/AttendanceDiagnosisTreatment RecommendationsCrisis/Risk AssessmentPsychiatric/Psychological EvaluationAlcohol/Substance Use TreatmentProgress/Participation in TreatmentTreatment Summary NotesBilling StatementsIEP/504PlanETR/MFEFERPA/Educational RecordsOther, please specify below
Other Information Defined:
Duration and Revocation of Authorization
This authorization is good for a period of 1 year from the time of signing. I understand that I can revoke this authorization at any time prior to that date by contacting the practice in writing.

I understand that if the practice has already shared the information authorized here at the time I revoke this authorization, then it is too late to prevent that information from being shared.

I understand that the practice cannot make completion of this authorization a condition for any treatments or benefits I am entitled to, unless this authorization is necessary to determine eligibility for treatment or benefits or to pay for treatments I receive.

I understand that this information may be protected by Title 45 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 42 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules.
Authorization
I hereby authorize The Caring Collective LLC to release information as described above to, and request information from, the person or organization identified herein. I understand that the person or organization named above may not be subject to the same privacy laws and regulations as The Caring Collective LLC and may be able to further share the information disclosed under this authorization. I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.
Signed By*
Enter name and relationship if signing on the behalf of the client.
Today's Date*

MonthDayYear
Date
Signature
Should be Empty:

Release of Information

This form is to authorize The Caring Collective LLC to obtain and/or disclose information as specified below.