Authorization to Disclose Protected Health Information

4400 East Highway 20, Suite #306, Niceville, FL 32578* Phone (850) 797-2598 Fax (773) 492-8765

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.

Third Party for Bluewater Behavioral Health to (Check one)

Send records toRequest records fromBoth

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:

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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION