Consent to Release PHI

Select One: *

Authorization to Release/Exchange Protected Health Information Request for Records

Name of Client: *

Client Date of Birth: *

Date

I voluntarily authorize Genesis Counseling Center to use and disclose the protected health information described below to:

Name of Person or Organization: *

Address: *

Phone Number: *

Area Code Phone Number

Fax Number: *

Area Code Phone Number

I authorize Genesis Counseling Center to verbally communicate regarding my treatment with the above person or organization,

Subject to the following limitations:

I authorize Genesis Counseling Center to release my complete health record with the exception of the following information:

I request the release of my complete health record be sent to Genesis Counseling Center fax: 757-838-2573

Request From:

This authorization for release of information covers health records for the period shown below (or select to release for all past, present and future periods):

From Date:

Date

To Date:

Date

Or:

All Past, Present, and Future Periods

The purpose or need for this disclosure is: *

Care Coordination Personal Use Attorney School

I understand the following:

This   medical   information   may be   used   by   the   person   I   authorize   to   receive   this   information   for   medical treatment   o r   consultation,   billing   or   claims   payment,   or other   purposes   as   I   may   direct.
I   understand   that I may be denied services if I refuse to consent to disclosure for the purposes of treatment, payment, or healthcare operations. I will not be denied services if I refuse to authorize disclosure for other purpose s.
I understand that my substance use disorder records (if any) are protected under federal law, including the federal regulations governing the confidentia lity of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for b y the regulations.
I   understand   that   information   used   or   disclosed   pursuant   to   this   authorization   may   be   disclosed   by   the   recipient and   may   no   longer   be   protected   by   federal   or   state   law .
I have been provided a copy of this form.
I   understand   that   I   have   the   right   to   revoke   this   authorization,   in   writing,   at   any   time except to the extent that action has been taken in reliance on it . Unless I revoke my authorization earlier, t his   authorization   shall expire as follows :

Date, Event or Condition:

Signature of Client or Personal Representative: *

Clear

Date: *

Date

Printed name of Client or personal representative and his or her relationship to Client: *

Client/Guardian Contact Phone Number: *

Area Code Phone Number

Individuals requesting their own records will be charged a reasonable, cost-based fee for paper or electronic copies. Third parties requesting records (including attorneys) will be assessed a reasonable charge as permitted by Virginia law, including a search and handling fee not to exceed $20, $0.50 per page for up to 50 pages and $0.25 per page thereafter for paper for hard copies, $0.37 per page for up to 50 pages and $0.18 per page thereafter for paper for electronic copies, plus all postage and shipping costs (not to exceed a total of $150 for electronic copies Genesis Counseling Center has 30 days to process this request. This fee must be paid in full prior to release. Revised: 4/10/2020