WACC Release of Information

Washington Area Clinical Center

2905 Mitchellville Road Suite 204 Bowie, MD 20716 Phone: 301-701-6965 Fax: 240-293-4731 records@waccenter.com www.waccenter.com
All information that has been gathered on an individual is personal and private, and this information cannot be released without authorized written permission except as permitted by law. I understand that the information in the record of:
Patient Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth of Patient*

MonthDayYear
Date
Is personal and private, HOWEVER, I GIVE PERMISSION FOR:

Washington Area Clinical Center

2905 Mitchellville Road

Suite 204

Bowie, MD 20716

301-701-6965 (Phone)

240-293-4071 (Fax)
To*

Release and Receive Records from:To Release Only to:To Receive Only from:
Name of Person Authorized to Release or Receive Personal and Private Information*

First NameLast Name
Office or Organization
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Secure Email To Send Records
Secure Fax *

Area CodePhone Number
Address (If records shall be mailed)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records Being Requested or Released
I authorize the release of the following protected health information (Check all that apply)
Complete Chart Record (does not include billing information or radiographic images) Visit /Encounter Notes (If yes, specify dates or date range) Screenings and Assessments Hospital records Diagnosis Psychiatric Evaluation(s)*
Treatment Plan Attendance History Medication List Treatment Summary
I grant permission for records to be released

by Verbal CommunicationWritten Treatment Summary (Summarize main points, withhold details)Transmit full complete record by fax or mail
From Date Range*
To Date Range*
Purpose of Records Request*

Personal Request (Patient would like records)Transfer of careConcurrent/collaborative careContinuation of CareLegalInsurance RequestProviding Information about my TreatmentDisabilitySocial ServicesEmployment or SchoolOther
In compliance with state and/or federal laws, which require special permission to release otherwise privileged information, please release the following records.
Special Authoriztions

HIV / AIDSSexually Transmitted DiseasesTransfer of careConcurrent or collaborative careMental Health CareSubstance AbuseOther
Please explain the nature of your request and how you would like your records released.
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 cannot be disclosed without my written consent unless otherwise provided for by the regulations.
I also understand that I may revoke 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: Upon Discharge

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
Patient Signature*

Clear
Should be Empty:

Washington Area Clinical Center

Records Being Requested or Released