Release of Information

Client's Full Name:*

First NameLast Name

Client's Full Name:

Client Date of Birth:*

Date

I AUTHORIZE:

Transformations Health Services

3650 Muddy Creek Rd Cincinnati, OH 45238

Phone: 513-347-0375 Fax: 513-347-0376

To:

release information, obtain information, and exchange information with the person/organization in PART 1.

Organization Name And/or Person Name: *

Organization Name And/or Person Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Organization Name And/or Person Phone #:*

Please enter a valid phone number.

Organization Name And/or Person Fax #:

Please enter a valid phone number.

Specific dates/years of treatment:*

What information are you requesting to be released?*

All health information (excludes information from a chemical dependency program & psychotherapy notes) OR indicate the specific categories to be released.DiagnosisPsychological EvaluationsDischarge SummaryTreatment PlansSocial HistoryProvider/Hospital RecordsSchool/Criminal RecordsOther

Type a question*

I UNDERSTAND THAT:

My health information is protected by federal regulation (Alcohol & Drug Abuse Client Records, 42 CFR Part 2; and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Transformations Health Services Privacy Notice.
My refusal to sign this authorization will NOT affect my ability to obtain treatment. However, I understand that I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Transformations Health Services Privacy Notice outlines the procedure for revocation. This authorization will expire in one year from the date I sign or unless I request an earlier expiration in writing.
NOTE: This information has been disclosed to you from records whose confidentiality is protected from disclosure by State and Federal law. ORC 5122.31. 42 CFR Part 2, and/or ORC 3701 .243 prohibit you from making any further disclosure of it without the specific and informed release of the individual to whom it pertains, their authorized representative, or as otherwise permitted by law. A general authorization for the release of information is NOT sufficient for this purpose.
Communications resulting from this authorization will reveal that I receive services at Transformations Health Services.
Federal confidentiality regulations (42 CFR Part 2) prohibit re-disclosure of information from alcohol & drug abuse Client records. However, HIPAA requires Transformations Health Services to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA.

Date*

Date

Client OR Authorized Representative’s Signature:*

Representative’s Name:

Representative’s Relationship to Client:

Release of Information Consent Form

Client Information

PART 1

ORGANIZATION/INDIVIDUAL INFORMATION:

INFORMATION TO BE RELEASED

PURPOSE FOR DISCLOSURE: