Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information
As noted below the following are authorized to:*

Disclose InformationReceive InformationExchange Information
Regarding (Client Name)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name of Program/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.
Name of Program/Person Authorized to Receive/Disclose/Exchange Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Purpose of Disclosure- Select one

Continuity of CareDisability DeterminationOngoing TreatmentTreatment PlanningCollateral
Information to be Disclosed*

AttendanceCrisis AssessmentHIV/AIDS tests/resultsLab 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 below
Other specified information
Amount of Information to be Disclosed

Most recent episode of carePrevious three monthsOther, specify
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 I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken).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 Access For Change , LLC being inreceipt of the written revocation.
Select one of the following*

This authorization will expire upon the termination of treatment & services at Access For Change , LLC.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*
ClientGuardian
Date signed*

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.
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