I authorize Generations Family Health Center, Inc. to release/obtain all pertinent information regarding the patient’s treatment which may include information relating to medical, psychiatric, alcohol, and drug abuse, HIV/ AIDS, Sickle cell, to such facilities as is necessary for my treatment and care. I authorize Generations Family Health Center, Inc. to release/obtain all pertinent information regarding the patient’s treatment, including information relating to treatment for medical, psychiatric, alcohol and drug abuse, HIV/ AIDS, Sickle cell to any third party payor for the purpose of security payments for services to the physician or organization furnishing the service. This facility, its employees, officers and attending physician are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized therein.
I understand that the patient’s alcohol and/or drug treatment records are protected under State and Federal Confidentiality Regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records (see 42 USC290DD-2 for Federal laws and 42 C.F.R. Part 2 for Federal regulations, and Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed without parental or legal guardian consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent in writing at any time, except to the extent that action has been taken in reliance upon it.
I understand that I may revoke this authorization at any time, except where information has already been released pursuant to my authorization, provided that any such revocation is done in writing.
I understand that the information released here may be subject to re-disclosure by the recipient and may no longer be protected by the Health Center’s privacy practices or applicable privacy law.
I understand that Generations Family Health Center, Inc. may not condition the patient’s treatment on my provision of this authorization.