Release of Information

AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

Lookout Mountain CSB
* Denotes Required Field
Full Name of Individual Receiving Services *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Is the individual receiving services under the age of 18 and/or have a legal guardian?

Yes No
Full Name of Parent/Legal Guardian

First Name Last Name
Relationship to Individual Receiving Services:

Parent Legal Guardian
Parent/Legal Guardian Phone Number:
Section A: Use or Disclosure of Health Information
By signing this Authorization, I authorize the use or disclosure of my individually identifiable health information maintained by: Lookout Mountain Community Services
My health information may be disclosed under this Authorization to the following recipient

Release Information To Obtain Information From
Please select agency from list: *
Other agency has been selected, please enter agency name, address, phone below:
Section B: Scope and Use of Disclosure
Health information that may be used or disclosed through this Authorization is as follows
Release of Information:
This information may include, if applicable: Info pertaining to the identity, diagnosis, prognosis or treatment for alcohol or drug abuse maintained by a federally-assisted alcohol or drug abuse program; or; Info concerning the testing for Human Immune Virus and/or treatment for Acquired Immune Deficiency Syndrome and any related conditions. Privileged Communications between me and a psychiatrist, psychologist, licensed clinical social worker, licensed marriage and family counselor, or licensed professional counselor or between them concerning my communications with any of them.

All of the above Health information about me, including my clinical records created by Organization above. All health information about me as described in the preceding checkbox, excluding the following Specific health information including only
0/500
Section C. Purpose of Use or Disclosure:

The purpose(s) of this Authorization is (are):
Coordination of Care Continuation of Care Specifically, the following purpose(s)
0/500
Section D: Authorization Expiration
Expiration Date:

Month Day Year
*** AUTHORIZATION WILL EXPIRE AUTOMATICALLY ONE YEAR FROM TODAYS DATE ***
Section E: Other Information of Importance
1. I understand that this agency cannot guarantee that the Recipient will not redisclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information. However, if the disclosure consists of treatment information about a consumer in a federally-assisted alcohol or drug abuse program, the Recipient is prohibited under federal law from making any further disclosure of such information unless further disclosure is expressly permitted by written consent of the consumer or as otherwise permitted under federal law governing Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR, Part 2).
2. I understand that, except when I am (1) receiving research-related treatment or (2) receiving health care solely for the purpose of creating information for disclosure to a third party, I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from this agency.
3. I understand that I may revoke this Authorization in writing at any time, except that the revocation will not have any effect on any action taken by this agency in reliance on this Authorization before written notice of revocation is received by this agency. I further understand that I must provide any notice of revocation in writing to the Privacy Officer at this agency.
I have read and understand the terms of this Authorization and its use for disclosure of my health information.

SIGNATURE:

Signature below must be provided by either:
1. The individual served whom is 18 years of age or older whom doesn't have a legal guardian, OR
2. The legal guardian if the individual is a minor under the age of 18 or is an individual whom has been assigned a guardian by legal authority.
Signature *

Clear
Typed Name of Individual Signing Form: *

First Name Last Name
Signature Date:

Month Day Year
Should be Empty:

AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

Section A: Use or Disclosure of Health Information

Section B: Scope and Use of Disclosure

Release of Information:

Section D: Authorization Expiration

Section E: Other Information of Importance