Authorization For Use and Disclosure of Substance Use Disorder Information

Authorization For Use and Disclosure of Substance Use Disorder Information
Client's Legal Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
I authorize the disclosure of all information and records from Northwestern Mental Health Centers Substance Use Disorder program to my other mental health care providers at Northwestern Mental Health Center who are not directly involved in the program. I understand that Northwestern Mental Health Center Staff, not directly providing care to me, do not have access to my records. The purpose of this disclosure is for treatment, including coordination of care, and for the health care operations of Northwestern Mental Health Center. *

Yes No
I authorize the disclosure of information to other Substance Use Disorder programs in which I participate or am registered. *

Yes No
I authorize the use and disclosure of my health information as described above. I understand that if I do not sign for disclosure within Northwestern Mental Health Center and/or between other Substance Use Disorder providers and Northwestern Mental Health Center regarding continuity of care, Northwestern Mental Health Center may choose not to initiate treatment or may limit treatment options.

I understand that I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it. I understand that his authorization will expire 12 months from the date of signing this authorization.

A photocopy or fax of this authorization will be treated in the same manner as the original.
Please indicate your relationship *

Self Parent Legal Guardian Conservator Health Care Agent/Health Care Power of Attorney
Parent Name *

First Name Last Name
Name of Legal Guardian *

First Name Last Name
Name of Conservator Health Care Agent / Health Care Power of Attorney *

First Name Last Name
My signature indicates that I am legally authorized to sign on behalf of the client.
My signature indicates that I am legally authorized to sign.
Signature *

Clear
Date *

Month Day Year
Should be Empty: