• AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

    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

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  • 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

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

  •    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.

  •    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.

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

  • 4. Purpose: This authorization is made:

  •    At my request.

  •    For the following purpose(s):      

  • Expiration: This authorization with expire on   Pick a Date   (1 year) or      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.      
    6. Signature. I am making this authorization voluntarily and have had full opportunity to read and consider the content of this

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  • WWW.BLUEWATERBEHAVIORALHEALTH.COM

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