Release of Information

Authorization for Use and Disclosure of Substance Abuse/Mental Health Information
I hereby authorize representatives of Capstone Behavioral Health to release/obtain information to/from:
Individual/Agency with whom information will be exchanged*
Address and Phone Number of individual releasing/obtaining information
The information being released/obtained will be regarding the following individual:
Client's Name*

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
Information to be disclosed/obtained (check all that apply):

Attendance/Compliance InformationFamily History and Social InformationProgress NotesTreatment PlansPsychological History/Treatment SummaryAlcohol/Substance Use SummaryAssessment/Evaluation ReportsDischarge SummaryDrug Screening ResultsOther
Purpose of Release

Continuity of TreatmentCoordination of CareContact with Referral SourcesAlcohol/Drug Treatment FacilitationCase ManagementAssessment/EvaluationFollow-upFamily Involvement/SupportOther
As the person signing this consent, I understand that I am giving my permission to the above-named person/agency for disclosure of protected health information as defined under the Health Insurance Portability and Accountability Act (HIPAA). I understand that once my protected health information is used/disclosed pursuant to this authorization, the information may no longer be protected by the privacy regulations and may be subject to redisclosure by the recipient(s). I understand that I have the right to revoke this authorization at any time. My revocation must be in writing. I am aware that my revocation is not effective to the extent that I have authorized the use and/or disclosure of my health information and such use and/or disclosure has already occurred. I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of. Persons/agencies who request information under this release may use a copy or facsimile of this form in place of the original signed authorization form. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from Capstone Behavioral Health
This authorization will automatically expire 1 year from the date I sign, unless otherwise revoked or an earlier date is specified (date not to exceed 1 year). Please specificy if you would like this authorization revoked at an earlier date:
Revocation Date If Prior to One year (Only select if you want to end communication prior to one year):

MonthDayYear
Date
By signing this form, I acknowledge that I have read and understand this Authorization and had a chance to ask questions and receive adequate answers about the disclosure of the health information. I authorize the use/disclosure of my health information in the manner described above. Additionally, I have been provided a copy of this form.
Client's Signature

Clear
Date of Signature

MonthDayYear
Date
Witness Signature

Clear
Date of Signature

MonthDayYear
Date
If Client is under 19 years of age the Parent/Legal Guardian must sign.
Parent/Guardian Signature

Clear
Date of Signature

MonthDayYear
Date
Should be Empty:

Authorization for Use and Disclosure of Substance Abuse/Mental Health Information