Zohar Health: Authorization for Disclosure: General

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Authorization for Disclosure

Phone: (301) 250-0404 | Fax: (301) 637-7970 | www.ZoharHealth.com
Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information)
and Confidential HIV/AIDS-related Information
Client's Full Name*

First NameLast Name
Client's Date of Birth*

MonthDayYear
Client's Address*

Street Address

Apt/Suite

CityState / Province

Postal / Zip Code
Client's Email*
example@example.com
Client's Phone Number*

Area CodePhone Number
Last four numbers of Client's SSN# (optional)
Name of the person or entity who will receive and or release the information ( Not Zohar Health)*

First NameLast Name
Relationship of the person or entity who will receive and or release the information on behalf of me*

Family memberTherapistMedical providerSchoolOther
Phone Number of the person or entity who will receive and or release the information*

Area CodePhone Number
Fax Number of the person or entity who will receive and or release the information

Area CodePhone Number
E-mail Address of the person or entity who will receive and or release the information
example@example.com
I, or my authorized representative, request Zohar Health to receive and or release verbal, written and or electronic health information regarding my care, including my treatment plan, status, updates, and progress for collaboration and coordination of care, as set forth on this form, the validity of which ends one year from today.

I understand that:

1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDS-RELATED INFORMATION.

2. This information is subject to release for the purposes stated above and may not be used by the recipient for any other purpose unless permitted by federal law. I understand that the information disclosed by this authorization, except for alcohol and drug abuse patient records as defined in 42 CFR part 2 , may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and accountability act privacy rule (45 CFR Part 164), and the Privacy Act of 1974 (5 USC 552a).

3. I have the right to revoke this authorization at any time by writing to the provider. I understand that I may revoke the authorization except to the extent that action has already been taken based on this authorization.

4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.
All items on this form have been completed, my questions about this form have been answered and I acknowledge I have an opportunity to have a copy of this form.
Signature of Client or representative authorized by law ("Signer"):*
Name of the "Signer" above*

First NameLast Name
Is the "Signer" above someone other than the Client?*

YES - someone other than the Client signed this form.NO - the Client signed this form.
Relationship of "Signer" to Client (self/therapist/medical provider/mother/father/etc.)*
Signer's City*
Today's Date (Start Date of Authorization) *

MonthDayYear
Should be Empty: