• Authorization to Release/Exchange Protected Health Information

  •  /  /
    Pick a Date
  • I voluntarily authorize Genesis Counseling Center to use and disclose the protected health information described below to:

  •  -
  •  /  /
    Pick a Date
  •  /  /
    Pick a Date

  • 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 :
  • Clear
  •  /  /
    Pick a Date
  •  -
  • 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

  •  
  • Should be Empty: