Release of Information

Client Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Apt #

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Name of Program/Person Authorized to Disclose/Receive/Exchange Information*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Fax #*

Area CodePhone Number

This release authorizes:*

The Disclosure of InformationThe Receipt of InformationThe Exchange Information

Amount of Information to be Disclosed*

All dates of service availableMost recent episode of carePrevious yearSpecific Dates as noted below

Specified Date range:

Information to be Disclosed:*

Purpose of Disclosure- Select one*

Select one of the following*

This authorization will expire upon the termination of treatment & services at True Balance Ltd.This authorization will expire one year from the date signedThis authorization will expire on (specify below)

Authorization expiration date:

Signature*

Name*

First NameLast Name

Select*

ClientGuardianOther

Date signed*

Date

NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.

16016 233rd Street, Little Falls, MN 56345

Release of Information