RecoveryLink - Participant Release of Information

Participant Release of Information

Participant Consent to Release Information To Third Party
Consent to Release Information

Please review this document and fill in the information related to the third party you consent to release your recovery related and protected health information to, the purpose for this release, and the duration of this release.
Participant Name*

First NameLast Name
Email
example@example.com
Date of Birth*

MonthDayYear
Date
What is the name of the third party you are authorizing release of information to?*
What information are you releasing for disclosure?*
Who are you authorizing to release your information?*
What purpose are you authorizing the release of your information for?*
By signing this form,

I agree that I understand that my substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, I understand that I can withdraw the consent to receive services at any time. If not otherwise withdrawn, this consent will expire 365 days from the date of signaure on this release.

I understand that I may be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or healthcare operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
Date of Signing*

MonthDayYear
Date
Participant or Authorized Representative Signature*

Clear
If signed by authorized representative, please describe authority to sign on participant's behalf:
Should be Empty: