Notice to client and receipt of records
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2) and New Jersey Public Law 303. This Release of Information demonstrated compliance with the Health Insurance Portability and Accountability Act (HIPPA), Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR 160 and 164 and all federal regulations and interpretive guidelines promulgated thereunder. The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains as otherwise permitted by 42 CFR Part 2 New Jersey Public Law 303. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
I have been informed and understand that this authorization is subject to revocation to me at any time except to the extent that Center for Assessment and Treatment has already taken action in reliance on it. If I do not revoke this authorization, it will automatically expire 1 year from the date of signature unless otherwise noted. Once the requested protected health information is disclosed, the Privacy Regulations may no longer protect it if the PHI’s recipient rediscloses it. Furthermore, I understand that despite all care taken, information is occasionally received by a party not intended to be the recipient. I hereby release Center for Assessment and Treatment from all liability should this information be received by someone other than the above-intended recipient. I further understand that the information disclosed may include psychiatric, drug/alcohol abuse and/or HIV data.
I also understand I am not under any obligation to sign this release. I will receive treatment regardless of my decision to sign a release.