Release of Information 42-C

Jordan West Family Counseling

Authorization for Release of Information 42 C.F.R. part 2
I hereby authorize Jordan West Family Counseling to release information to and/or receive information from the record of:*

Consumer NameDate of BirthCase#
Release to and/or receive from:*

Name of Individual, Facility or Organization Information is authorized to be shared withatFax#
The specific purpose of the disclosure authorized is:*

Coordination of ServicesDetermination of BenefitsAt the request of the individualLegal Investigation or ActionChanging PhysiciansPayment of Insurance claimsOther
METHOD OF DISCLOSURE:*

VerbalWrittenFaxSecure e-mail
Information JWFC is authorized to RELEASE:

Behavior informationPsychological/Psychiatric EvaluationPhysician OrderPhysician Progress NoteMedication ReviewDischarge SummaryClinical AssessmentIndividual Plan of Service (IPOS)Periodic ReviewHealth Care AssessmentClinical Progress NoteCrisis Reports/ScreeningsServices/Programs ParticipationOther
Information JWFC is authorized to RECEIVE:

Behavior informationPsychological/Psychiatric EvaluationPhysician OrderPhysician Progress NoteMedication ReviewDischarge SummaryAssessmentTreatment Plans including medication listLaboratory ReportX=ray ReportEKG ReportAcademic InformationCourt records/legal documentsOther
The release of HIV/AIDS/ARC information:*

I ALLOW the release of HIV/AIDS/ARC information.I PROHIBIT the release of HIV/AIDS/ARC information.
Consumer Initials: Completing this box is mandatory and does not indicate whether or not an individual has HIV/AIDS/ARC*

Clear
I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. pts 160 & 164, and Utah Code 26-3-7 (Disclosure of health data - Limitations) and cannot be disclosed without my written consent unless otherwise provided for by the regulations.

I also understand that I may revoke verbally or in writing this consent at any time except to the extent that action has been taken in reliance on it and that in any event this consent expires automatically as follows: Termination of services; purpose achieved; one year from signature date, or whichever occurs first.

I understand that I may refuse to sign the authorization. I understand that I might be denied services if I refuse to consent to a disclosure for other purposes of treatment, payment, or health care operations. I will not be denied services if I refuse to consent to a disclosure for other purposes.
I understand that I may inspect or copy the individually identifiable health information or protected health information (PHI) to be used or disclosed. I have received a copy of this release.
Signature of Consumer*

Clear
Date

MonthDayYear
Date
Parent or Guardian Signature

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Jordan West Family Counseling