Release of Information

1
Client Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
I authorize The Resilience Group to release information and to obtain information from:
Provider Name/Organization
Street Address
City
State
Zip Code
4
Mental / Physical Health Information that may be released:
Presence and Progress in Treatment
Assessments
Diagnoses
Tx/Recovery Plans
Psychiatric Summary
Medication Records
Demographic Information
5
Drug / Alcohol Treatment Information that may be released:
Presence and Progress in Treatment
Assessments
Diagnoses
Tx/Recovery Plans
Psychiatric Summary
Medication Records
Demographic Information
6
Additional Information that may be released:
HIV/AIDS Information
Gender Therapy Assessment/Treatment
Other
7
Reason for release:
Provide continuity of care
Compliance with program
Specify
Personal Use
Legal Purposes
Social Security/disability
Insurance/Managed Care
8
Dates of Authorization
Authorization begins on:
Authorization ends on:
9
I understand that my health information is protected under the federal regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 that re-disclosure is prohibited, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 C.F.R. Parts 160 and 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. The information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer will be protected by the HIPAA Privacy Law.

review and understand the Notice of Privacy Practices;

this authorization is subject to revocation at any time, except to the extent that action has been taken in reliance on the authorization;

inspect and receive a copy of the material to be released;

request restrictions on how my health information is used and disclosed;

and receive a copy of this authorization and the Notice of Privacy Practices
10
Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format, or electronically and in person on progress, lack of progress, and all other information that pertains to treatment. This may include but is not limited to court appearances, treatment teams, court or treatment staffing or any other involvement required for treatment. You also authorize The Resilience Group to meet with my child at his/her school as school schedule permits. This form has been fully explained and I certify that I understand its contents. I understand that (agency) may not condition treatment on obtaining this consent/authorization from me.
11
Client Signature* This field is required.
Clear
12
Parent / Guardian Signature (if applicable)
Clear
13
Parent / Guardian Name (if applicable)
First Name
Last Name
14
Date* This field is required.
Date
Month
Day
Year
Should be Empty: