ASTRA BH RELEASE OF INFORMATION

PATIENT'S FULL NAME*

First NameLast Name

DATE OF BIRTH*

Date

Name of Patient Representative *if applicable

Relationship to Patient *if applicable

TOFROM

ASTRA BEHAVIORAL HEALTH OFFICE*

1013 Granite Drive, Bardstown, KY 400042000 Ring Road, Elizabethtown, KY 427014010 Dupont Circle Ste 210, Louisville, KY 40207420 N. Loretto Road Suite 200, Lebanon, KY 40033162 S Buckman St, Shepherdsville, KY 40165

Astra Location

TOFROM

NAME OF PERSON, AGENCY OR ORGANIZATION *

ADDRESS

Street Address

Street Address Line 2

CityState

Zip Code

PHONE NUMBER

Please enter a valid phone number.

FAX NUMBER

Please enter a valid FAX number.

Please select one or more records in which you wish to release to the above person, agency or organization:

DATE(S) OF SERVICE*

Please select one, or more, purpose(s) for the release of your protected health information:

I understand that pursuant to KRS 304.17A-555-Patient's Right of Privacy Regarding Mental Health or Chemical Dependency-Authorized Disclosure, my protected health information, used and/or shared under this authorization may not be shared again by the recipient of the information beyond the purpose for which my authorization was given without first obtaining my specific written consent to re-disclose. Additionally, I understand that my information prohibits the recipient to further disclose any information without written consent unless otherwise permitted by Federal Law 42 CFR Part 2. I am aware that if the person or entity that receives this information is not a healthcare provider or plan covered by federal privacy regulations, this information may be re-disclosed and no longer be protected by these regulations.

I understand that medical records released pursuant to this authorization could contain information concerning drug-related conditions, alcoholism, psychological conditions, psychiatric conditions and/or blood borne infectious diseases, which are subject to federal and/or state restrictions on disclosure. The federal regulations restrict any use of protected health information to criminally investigate or prosecute any alcohol and/or substance use patients.

I understand I have the right to revoke this authorization in writing to an Astra Behavioral Health location listed above at any time with the exception that the revocation will not apply to information already released in response to this authorization. Furthermore, per 94 HC250, I am entitled to one (1) free copy of my medical record. Additional requests may be subject to fees. I understand that in any and all authorized releases of information, the "minimum necessary" rule will apply. I understand that my signature on this form will not affect my condition for treatment, payment, enrollment or eligibility pertaining to benefits.

This authorization automatically expires one (1) year from the date signed, unless otherwise specified below:

Specify change in length of authorization expiration - if applicable

SIGNATURE OF PATIENT OR PATIENT REPRESENTATIVE*

WITNESS SIGNATURE

TODAYS DATE*

Date

RELEASE OF PROTECTED HEALTH INFORMATION

I, THE PATIENT, GIVE AUTHORIZATION TO DISCLOSE MY PROTECTED HEALTH INFORMATION BETWEEN THE PARTIES LISTED BELOW

THE FOLLOWING PROTECTED HEALTH INFORMATION MAY BE DISCLOSED:

PURPOSE FOR RELEASE OF PROTECTED HEALTH INFORMATION: