RCIC - RELEASE OF INFORMATION

CLIENT NAME: *

DATE: *

Date

DATE OF BIRTH: *

Date

SOCIAL SECURITY NUMBER: *

NAME OF PERSON AND/OR PROGRAM RECEIVING AND/OR RELEASING INFORMATION:

PHONE NUMBER:

FAX NUMBER:

NAME OF PERSON AND/OR PROGRAM RECEIVING AND/OR RELEASING INFORMATION:

RIVER CITY INTEGRATIVE COUNSELING

5511 STAPLES MILL ROAD SUITE 300, RICHMOND, VA 23228

PHONE NUMBER: 804.681.2525

FAX NUMBER: 804.230.0998

HEALTHCARE INFORMATION RELATING TO MENTAL/BEHAVIORAL HEALTH, AND/OR ALCOHOL AND DRUG ASSESSMENT, TREATMENT, AND DISCHARGE PLANNING; MEDICAL HISTORY; HOSPITALIZATIONS; MEDICATION; ETC. ACADEMIC/SCHOOL RECORDS, PSYCHOLOGICAL/ACHIEVEMENT TESTS EMERGENCY CONTACT

HIV-related information and drug and alcohol information contained in the parts of the record indicated above will be released through this consent unless otherwise indicated.

Do Not Release

MAIL EMAIL PICK-UP VERBAL FAX DELIVER FACE TO FACE

THE EXECUTION OF THIS FORM DOES NOT AUTHORIZE THE RELEASE OF INFORMATION OTHER THAN THAT SPECIFICALLY DESCRIBED ABOVE. THE INFORMATION REQUESTED ON THIS FORM IS SOLICITED UNDER TITLE 38, U.S.C. THE FORM AUTHORIZES RELEASE OF INFORMATION IN ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 42 CFR PART 2, 45 CFR PARTS 160 AND 164, 5 U.S.C. 552A, AND 38 U.S.C. 5701 AND 7332 THAT YOU SPECIFY. RECIPIENTS OF THIS INFORMATION ARE FORBIDDEN FROM RE-DISCLOSURE WITHOUT THE SPECIFIC FURTHER INFORMATION AUTHORIZATION AS CITED BY THE CODE OF FEDERAL REGULATIONS SECTION 2.31 OF PI.L 93-282 42 PART 2. I UNDERSTAND THAT THIS AUTHORIZATION MAY BE WITHDRAWN AT ANY TIME IN WRITING, EXCEPT TO THE EXTENT THAT THE AGENCY OR THE PERSON WHO IS TO MAKE THE DISCLOSURE HAS ALREADY ACTED IN RELIANCE ON IT. THIS AUTHORIZATION WILL REMAIN IN EFFECT THROUGHOUT THE COURSE OF TREATMENT AND FOR A MAXIMUM OF 90 DAYS FROM DISCHARGE UNLESS OTHERWISE WITHDRAWN. I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY AND THAT I MAY REFUSE TO SIGN THIS FORM. MY REFUSAL TO SIGN WILL NOT AFFECT MY ABILITY TO OBTAIN TREATMENT.

SIGNATURE OF CLIENT: *

Clear

DATE: *

Date

SIGNATURE OF LEGAL AUTHORIZED GUARDIAN (IF APPLICABLE):

DATE:

Date

SIGNATURE OF RIVER CITY STAFF:

DATE:

Date

AUTHORIZATION FOR THE RELEASE OF CONFIDENTIAL INFORMATION

SECTION I: IDENTIFICATION INFORMATION

SECTION II: PURPOSE OF INFORMATION/INFORMATION TO BE RELEASED

SECTION III: INFORMATION WILL BE TRANSMITTED VIA:

SECTION IV: AUTHORIZATION