AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

Journey to Healing, PLLC
As noted below the following are authorized to:*

Disclose InformationReceive InformationExchange Information
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name of Organization/Person Authorized to Disclose/Receive/Exchange Information*
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.
The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services.*

By checking this circle, you are confirming disclosure of information.
Information to be Disclosed*

AssessmentDischarge/Transfer SummaryPsychosocial EvaluationContinuing Care PlanTreatment Plan or SummaryProgress in TreatmentCurrent Treatment UpdateDemographic InformationPresence/Participation in TreatmentOther
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 I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken).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 Journey to Healing, PLLC receipt of the written revocation.
Expiration - Unless revoked prior, this authorization expires on the following date: Date (##-##-####) of expiration as noted below:*
One hundred and eighty (180) days from the date this Authorization is signed.
Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format, or electronically.
Redisclosure

Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. I will be given a copy of this authorization for my record.
Signature*

Clear
Signature of Patient/Client
Date signed*

MonthDayYear
Signature of Parent, Guardian, or Personal Representative

Clear
Signature of Parent, Guardian, or Personal Representative
Date

MonthDayYear
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.
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