Spectrumbehavioralhealthny.com-General Informed Consent to Release/Receive Information

SPECTRUM BEHAVIORAL HEALTH

New In-take Fax: 845-485-8780

Poughkeepsie Fax: 845-452-7546 / Fishkill Fax: 845-897-3376 / Kingston Fax: 845-331-1479
General Informed Consent to Release/Receive Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
I hereby give permission to Spectrum Behavioral Health to release / receive information to / from:
Person*
Agency or Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax Number
This information is needed for:*
My consent is subject to revocation at any time (except to the extent that action has been taken in reliance on my consent) and expires in 1 year
Date of revocation if earlier than 1 year:*

MonthDayYear
I understand that the release of information may impact my status with:*

ProbationParoleSocial ServicesOther
Patient/Guardian Signature:*

Clear
Date Signed*

MonthDayYear
Date
Note

FOR PERSONS RECEIVING TREATMENT FOR ALCOHOL OR DRUG ABUSE, ANY INFORMATION DISCLOSED AS PER THIS RELEASE IS PROTECTED BY FEDERAL LAW. FEDERAL REGULATIONS (42 CFR PART 2) PROHIBIT ANY RE-RELEASE OR FURTHER DISCLOSURE OF INFORMATION WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS. A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFROMATION IS NOT SUFFICIENT FOR THIS PURSPOSE
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