Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information [3793:2-1-06(H)]
As noted below the following are authorized to:

Disclose InformationReceive InformationExchange Information (Disclose and Receive)
Regarding (Patient Name)

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of Program/Person Authorized to Disclose/Receive/Exchange Information
Relationship to Above
(i.e: Parent, Primary Care Provider, Therapist, Hospital)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax #
Please enter a valid phone number.
Email
example@example.com
Purpose of Disclosure- Select one

Continuity of CareDisability DeterminationOngoing TreatmentTreatment PlanningCollateral
Information that can be disclosed

AttendanceCrisis AssessmentLab tests including medication resultsPhysician's Orders/Medical NotesPregnancy Test resultsPrenatal Care ReceivedProgress in TreatmentPsychiatric EvaluationPsychological EvaluationInformation on Mental Illness and /or TreatmentUrine TestingOther, please specify belowNONE/REVOKE ACCESS
Other specified information
Amount of Information to be Disclosed

Most recent episode of carePrevious 3 monthsPrevious 12 monthsAll episodes of careOther
Other specified amount of information
I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon Carolina Complete Psychiatry receipt of the written revocation.
Select one of the following

This authorization will expire upon the termination of treatment & services at Carolina Complete Psychiatry.This authorization will expire upon the disposition of the crisis assessment / crisis intervention & coordination of care .This authorization will expire when (specify below)This authorization will expire on (specify below)
Specifications (condition/date corresponding to above selection)
Signature
PatientParent/Legal Guardian
Date signed

MonthDayYear
Date
Email
example@example.com
REVOKE ACCESS:

At any point and time, the patient may chose to revoke access to the person(s) listed above. Should you chose to REFUSE OR REVOKE ACCESS of medical information to the person listed above, please sign here:
Signature

Clear
Date

MonthDayYear
Date
NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION 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 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.
Should be Empty: