This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (42 C.F.R. Part 2) and state requirements (Iowa Code Ch. 22) prohibits further disclosure without the specific written consent of the client or as otherwise permitted by such law and/or regulations. A general authorization for the release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or mental health information.
* ** Only the subject may authorize release of substance abuse information unless the subject is under legal age or incompetent as defined by statute.
Only persons 18 years of age or his/her legal representative may authorize release of mental health information.
Sharing information: It is the responsibility of all agencies listed to provide requested information. The recipient of the information is responsible for maintaining confidentiality of the information.
Integrative Counseling Solutions, Inc. ■ 1200 Valley West Dr., Suite 508 ■ West Des Moines, IA 50266 ■ (515) 267-1340 phone ■ (515) 267-1355 fax