Release of Information

Authorization for Release of Treatment Information
Client Name*

First NameLast Name
Birth Date*

MonthDayYear
Social Security Number*
ex: 000-00-0000
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
I authorize Community Counseling Center:

To release information toTo request information from
Name of Recipient or Organization:*
ex: John Doe, Probation, Doctor's office....
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Type of information to be disclosed:*

AttendanceBilling / Accounting InformationInformation on mental illness and / or treatmentInformation on substance use disorders and / or treatmentDiagnosisDiagnostic assessmentProgress in treatmentProgress notesSchedulingUrine TestingHIV / AIDS testing or statusLab resultsPregnancy testingPrenatal CareOther
Purpose of Disclosure:

Continuity of CareEvaluationTreatmentOther
I understand and I , and/ or my parent or guardian if appropriate, may revoke this authorization at any time, except to the extent that action has been taken in reliance on it. If not previously revoked this authorization terminates on the following specific date, event or condition.

I understand that treatment, payment, enrollment, or eligibility for benefits will be based on whether or not I sign this authorization.
Number of days Active*

60 days180 days365 days
Date of expiration*

MonthDayYear
(For clients receiving mental health services, consent shall expire 90 days after authorization, unless a different time period has been designated except that authorization may not be granted for longer than 365 days)

Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by Federal confidentiality rules. 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 or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse by the client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA’), 45 C.F.R. parts 160 and 164. (These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.)
Other action needed:

YesNoOther
Signature*

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Authorization for Release of Treatment Information