AUTHORIZATION FOR RELEASE OF INFORMATION
PRIVACY STATEMENT: Disclosure of the social security number is voluntary and is requested for the purpose of accurate identification.
Failure to disclose a social security number will not affect the disclosure of other information. The institution will not condition treatment
on your agreement to authorize disclosure of your health information. The institution may, however, require that you authorize disclosure
of your health information if needed to make a determination about your eligibility for benefits or enrollment in a health plan.
INSTRUCTIONS: Provide information as it existed when the service was provided.
Name of Client: (Last, First, Middle Initial) SSN or Student ID:
Current College:
Date of Birth:
Street Address:
City:
State:
Zip Code:
CLIENT RELEASE AND SIGNATURE
1. I Hereby Authorize (person/agency to release the information)
Name of Person/Agency: __________________________________________________________________________
Street Address: _________________________________________________ Fax:______________________
City, State, Zip:__________________________________________________ Phone:_____________________
2. To Release Information To (person/agency to receive information)
Name of Person/Agency: __________________________________________________________________________
Street Address: _________________________________________________ Fax:______________________
City, State, Zip:__________________________________________________ Phone:_____________________
3.
The Following Information Is Requested: (Be Specific)
4. The Information Identified Above Will Be Used For: (List Each Purpose)
5. This Authorization to Disclose Information Remains in Effect Until: (Date)
OR: (Specific Event Terminating Operation of the Release)
CLIENT CONSENT:
This authorization is voluntary and remains in effect until the above date or event, unless specifically revoked by written notice to
the agency or person. Refer to the Notice of Privacy Practices for further description of revocation rights. Any information
disclosed prior to written revocation of this authorization shall not be a breach of confidentiality. A photocopy of this
authorization
is as effective as the original. Unless otherwise agreed in writing, information may be disclosed under this
authorization in any
form or medium, including oral, written, or electronic transmission.
Signature of Client: Date:
Signature of Parent/Guardian or Custodian (if needed and Relationship):
Date:
Signature of Witness (if needed): Date:
CHECK IF APPLICABLE - NOTICE TO WHOMEVER DISCLOSURE IS MADE CONCERNING ADDICTION RECORDS
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 this information unless further disclosure is expressly permitted
by the
written authorization of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general
authorization for
the disclosure 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 abuse patient.
NOTICE: Except for information subject to 42 CFR Part 2, information disclosed to another entity may potentially be redisclosed,
in which case it may not be protected by state or federal law.
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