Release of Information Consent

AUTHORIZATION TO RELEASE/OBTAIN CONFIDENTIAL INFORMATION
Section A

Use or Disclosure of Health Information
By signing this form, I authorize the disclosure/acquirement of my protected health information maintained by:

Ku Aloha Ola Mau

1130 N. Nimitz Hwy C-302

Honolulu, HI 96817

(808) 538-0704

My health information may be disclosed to:
Name:*
Address:
Phone:
Section B

Scope and Use of Disclosure
Information that may be disclosed based on this authorization is as follows: (check only those that apply to this disclosure)*

AttendanceDrug Screen ResultsDischarge SummaryPsychiatric EvaluationISPPhysician OrdersTreatment SummaryLab ReportsMedication DoseUA ResultsVerificationDose HistoryDiagnosisTransportationPhysical Examination & Nursing AssessmentPresence on SiteAppointment Information / SchedulingConfirmation of Program EnrollmentPharmacy
Pharmacy name
Section C
For the Purpose of:*

Coordination of treatmentTo meet the requirements of courtProbation/paroleContinuity of careFamily involvement
Section D

Forms of Information (Initial all forms in which consent applies):
Verbal

Initials Clear
Written

Initials Clear
Electronic/Facsimile

Initials Clear
Section E

Other Important Information
This consent may be revoked at any time, upon notice of the person who has signed below, except when action has already been taken. Without revocation, this consent will expire one year from date of signature.

The types of medical information above cannot be released without my specific consent and knowledge. I hereby release Kū Aloha Ola Mau and its staff from all liability and all claims of any nature pertaining to the disclosure of information of any professional opinions, findings, or recommendations contained in these records.
I acknowledge that I have the option to have received a copy of this authorization:*

Initials Clear
Printed Name*
Phone Number*
Date of Birth:*

MonthDayYear
Signature*

Clear
Date:*

MonthDayYear
Select Your Clinic*
Redisclosure is prohibited. This information has been disclosed to you from records protected by Federal (42 CFR part 2), Federal Health Insurance Portability and Accountability Act (HIPAA 45 CFR, parts 160 & 164), and State (HRS 325-101) confidentiality rules. The Federal rules and State law prohibit further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2, HIPPA, and HRS 325-101. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Revised: April 2007 Rev: 3/2011 MQ
Should be Empty:

AUTHORIZATION TO RELEASE/OBTAIN CONFIDENTIAL INFORMATION

Section A

Section B

Section C

Section D

Section E