Authorization for the Release of Information

Authorization for the Release of Information
Client's Name

First Name Last Name
Client's Birthday

Month Day Year
The below listed agency/program/provider(s)/supervisor are authorized to:

Disclose Information Receive Information Exchange Information
Please list the Ravenwood Program/Provider(s) and Supervisors to whom disclosures may be made: *
Purpose of disclosure: (Please check all that apply) *

Coordinate Treatment To gather information for ongoing treatment Gather assessment information for treatment planning Provider Clinical Recommendations Copy records and release them to authorized people outlined above
Effective Dates of Authorization: (Can not be longer than 180 days) *
Type of Information to be disclosed *

Psychiatric Assessment Clinical Assessment Information Diagnosis Assessment Summary Drug & Alcohol Assessment Drug & Alcohol Family Information Psychological Testing Treatment Recommendations (Including AoD) Sexual Aggression Assessment Attendance in treatment Progress Notes Financial Needs Court Testimony & Records Medical History Hospitalization Records Medications Prescribed Lab Reports (including drug screen results) Progress in Treatment Educational Testing/Records Crisis Interventions Discharge Summary/Plan Risk Assessment HIV/Aids Related Diagnosis/Treatment
Amount of Information to be disclosed:

Information on most recent admission
Approved method for sending records adn communicating information:

Fax Secure Email Telephone Mail Pick Up
This authorization, unless revoked earlier, expires on my formal termination from treatment at Ravenwood Health not to exceed 180 days after signing the release, whichever occurs first. I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.

SUD Disclosure Statement:
Statement of Understanding: I (or other individual authorized to sign in lieu) confirm my understanding that, upon my request, I must be provided a list of entities to which information has been disclosed pursuant to the general designation.

I understand and acknowledge that the requested health information may contain information regarding physical and mental illness; HIV testing results or diagnosis; treatment of AIDS/AIDS-related conditions; and/or alcohol or drug abuse, all of which are protected under federal or state confidentiality regulations (42 CRF Part 2, 45 CFR Part 160 and 164, O.R.C. 3701.243, etc.) and these records cannot be re-disclosed without my written consent unless permitted by the regulations. I also understand that my mental health treatment records are protected by HIPAA but that if the recipient of my information is not subject to HIPAA, it may no longer be protected by state or federal law and therefore subject to re-disclosure to a third party

Revoking Authorization:
This authorization may be revoked in writing at any time except to the extent the program or person who is making the disclosure has already acted in reliance on it.
By signing below I authorize the information to be disclosed as outlined above. I understand that this authorization is good for 180 days from the date below unless I have elected for it to be good for a shorter period of time as outlined above.

Clear
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