APIA ROI

Consent for Release of Confidential Information

Serving: Anchorage, Atka, Nikolski, Saint George, Unalaska
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Parent/Legal Guardian

First NameLast Name
I grant permission for: Aleutian Pribilof Islands Association, Inc., Behavioral Health
1131 E. International Airport Rd., Anchorage, AK 99518
Main: 907-276-2700 Fax: 907-222-4279
Select which clinic you grant permission for:
To (check all that apply):
Name
Agency:
Address
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Regarding the following information (CHECK all that apply):

Other
For the following purposes (CHECK all that apply):

Other
I understand that my alcohol and/or drug treatment records are protected under Federal laws governing the confidentiality of substance use disorder records (42 C.F.R. Part 2) and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and cannot be disclosed without my written consent unless otherwise provided for by the regulations. Treatment and benefits will not be contingent on signing this ROI, except to the extent that an ROI is necessary under 42 CFR Part 2 for payment purposes. I also understand that I may revoke this consent orally, pursuant to 42 C.F.R. Part 2, or in writing at any time except to the extent that action has been taken in reliance on it (any information that has already been released cannot be recalled).
This consent will expire one year from date signed or on:
;however, it is revocable by client at any time with a written request for revocation.
Initals I received/declined a copy of this form.
Signature of Client or Legal Guardian
Date Signed by Client or Legal Guardian

MonthDayYear
Date
Signature of Therapist (added after submitted)
Date Signed by Therapist (added after submitted)

MonthDayYear
Date
To the Recipient of Confidential Information
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 further disclosure of this information unless further disclosure is expressly permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug patient.
Should be Empty:

Consent for Release of Confidential Information