• Consent to Treatment

    Consent to Treatment

  • PCP/Family Doctor Consent

    Consent & Authorization for the release of information
  • I         Consent for the release and authorization the disclosure and use of my protected health information by Journey Healthcare, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:

  • I also understand:

     

    1. That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether I sign this authorization, and that I may refuse to sign.
    2. That when either federal or state laws afford me more a stringent level of privacy protection than those regulated by 164.508, Journey Healthcare will always abide by the more stringent law.
    3. Journey Healthcare will only disclose my health information gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.
    4. That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your information could potentially disregard these and other laws.
    5. That this authorization expires 30 days after discharge from treatment episode.
  • Clear
  •  - -
    Pick a Date
  • I understand that I may revoke all or part of this authorization verbally or in writing.
    Please contact the office if you wish to revoke this consent.

    This Consent/Authorization complies with the Privacy Regulations contained within Federal Register Vol. 65, Part II, Part 164; SubPart E 164.508.


    PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law.  Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations.  A general release of medical or other information is NOT sufficient for this purpose.

  • Family Consent and Authorization for the release of information

    Famiy Consent
  • I         Consent for the release and authorization the disclosure and use of my protected health information by Journey Healthcare, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:

  • I also understand:

    1. That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether I sign this authorization, and that I may refuse to sign.
    2. That when either federal or state laws afford me more a stringent level of privacy protection than those regulated by 164.508, Journey Healthcare will always abide by the more stringent law.
    3. Journey Healthcare will only disclose my health information gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.
    4. That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your information could potentially disregard these and other laws.
    5. That this authorization expires 30 days after discharge from treatment episode.
  • Clear
  •  - -
    Pick a Date
  • I understand that I may revoke all or part of this authorization verbally or in writing.
    Please contact the office if you wish to revoke this consent.

    This Consent/Authorization complies with the Privacy Regulations contained within Federal Register Vol. 65, Part II, Part 164; SubPart E 164.508.


    PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law.  Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations.  A general release of medical or other information is NOT sufficient for this purpose.

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