Release of Information - Updated 09/2023

12557 Ravenwood Drive; Chardon, Ohio 44024

AUTHORIZATION FOR THE RELEASE OF INFORMATION
Client Name*
DOB*
Today's Date*

MonthDayYear
Date
The following agency/program/provider(s)/supervisor are authorized to*

disclosereceiveExchange information
External Agency/Program/Provider(s)/Supervisor *
External Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
External Agency/Program/Provider(s)/Supervisor Phone/Fax/Email*
This release will allow information to be released or disclosed with Ravenwood Health.
Purpose of Disclosure: (check all those that apply)*

Coordinate treatmentTo gather information for ongoing treatmentGather assessment information for treatment planningProvide clinical recommendationsCopy records and release them to authorized agency/program/provider(s)/supervisorOther Purposes (Specify Below)
Other Disclosure Purposes
Effective Dates of Authorization*

Release of information will expire upon termination from Ravenwood HealthRelease of information will expire on--specify date below
Please specify the expiration date below.
Type of Information to be disclosed: (check all those that apply)*

Psychiatric AssessmentClinical Assessment InformationDiagnosisAssessment SummaryDrug and Alcohol AssessmentDrug and Alcohol Family InformationPsychological TestingTreatment Recommendations (including AoD)Safety AssessmentSexual Aggression AssessmentAttendance in TreatmentProgress NotesFinancial NeedsCourt Testimony & RecordsMedical HistoryHospitalization RecordsMedications PrescribedLab Reports (Including Drug Screen Results)Progress in TreatmentEducational Testing/RecordsCrisis InterventionsDischarge Summary/PlanHCR-20 Violence Risk AssessmentHIV/Aids Related Diagnosis/Treatment
Amount of information to be disclosed*

Information on most recent admissionOther Amount of Information
Approved method for sending records and communicating information*

FaxTelephonePick upMailSecure Email
Client Signature and Date*

Clear
Parent and/or Guardian Signature and Date (if applicable)

Clear
Revocation: This authorization is subject to written revocation at any time except to the extent the program or person who is to make the disclosure has already acted in reliance of it.
I hereby revoke my consent in writing:

Clear
Witness signature:

Clear
12557 Ravenwood Drive; Chardon, Ohio 44024

Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see 42 CFR 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at 42 CFR 2.12(c)(5) and 42 CFR 2.65.

This authorization, unless revoked earlier, expires on my formal termination from treatment at Ravenwood Health unless otherwise stated. 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
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: