Authorization to Disclose Protected Health Information

4400 East Highway 20, Suite #313, Niceville, FL 32578* Phone (850) 797-2598 Fax (850) 807-5127

1. Patient Information

Name*

First NameLast Name

Date of Birth*

Date

SSN#:*

2. Authorization: I authorize the following third parties to disclose the above listed patient's protected health information in the manner described below in section 3.

Name of Third Party to Provide/Receive Information: Bluewater Behavioral Health, Inc

Name of Third Party to Provide Information or Receive Information from BBH*

Phone Number

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

Address:

City/State/Zip Code:

3. Scope of Authority: I authorize the disclose of my protected health information to the above-named individual/entity as follows: (Initial only one)

Initials I authorize the disclosure of ANY protected health information (except psychotherapy notes) that the above named individual/entity may request. If applicable, this information may include information pertaining to chronic diseases, behavioral conditions, communicable diseases including HIV or AIDS and/or genetic information.

Initials Also include any alcohol and substance abuse records, if applicable (indicate by initialing). This authorization to alcohol or substance abuse information unless specifically authorized above.

Initials I authorize the disclosure of ONLY the following protected health information to the above named individual/entity: Initials

4. Purpose: This authorization is made:

Initials At my request.

Initials For the following purpose(s):

Expiration: This authorization with expire on Date (1 year) or Initials at the end of treatment.
Revocation: I understand that I may revoke this authorization at any time by notifying Bluewater Behavioral Health, Inc in writing. Revocation will not apply to records already furnished in reliance upon this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules or privacy laws. Initials
6. Signature. I am making this authorization voluntarily and have had full opportunity to read and consider the content of this

Signature of Patient/Guardian:*

Date:*

Date

Witness Name:

Signature of Witness:

WWW.BLUEWATERBEHAVIORALHEALTH.COM

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION