Purpose of Release: ☐ Continuation of Care ☐ Work Comp ☐ Disability Determination ☐ Personal
☐ Insurance Claim ☐ Legal ☐ Other: __________________________
Information to be Released:
☐ Crisis Plan ☐ Physician Notes ☐ RN Notes
☐ Progress Notes ☐ Psychiatric Evaluations ☐ Assessments
☐ School Records ☐ Medical Reports ☐ Treatment Plans
☐ Psychological Summary ☐ Medications ☐ Discharge Summary
☐ Guardianship Paperwork ☐ Written & Verbal Communications Pertinent to Treatment
☐ Other (Please be specific): _______________________________________________________________________________
Date range of records for release: ___________________ to ______________________
Once information is disclosed pursuant to this signed authorization, I understand that the federal health privacy law (45 C.F.R. Part 164) protecting health information may
not apply to the recipient of the information and, therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit redisclosure. When this
agency discloses mental health and developmental disabilities information protected by state law or substance abuse treatment information protected by federal law (42
C.F.R. Part 2), we must inform the recipient of the information that redisclosure is prohibited except as permitted or required by these two laws.
I understand that I may refuse to sign this authorization form. Refusal to sign will not be a condition to obtain treatment, payment for or coverage of services, or eligibility
for benefits or enrollment.
I understand that, with certain exceptions, I have the right to revoke this authorization at any time. If I revoke this authorization, I must do so in writing. I understand that
the revocation will not apply to the information that has already been released in response to this authorization.
I have had the opportunity to read and consider the contents of this authorization. I confirm that the contents are consistent with my direction and a copy of this form is as
valid as the original to allow release of my records.
If not revoked earlier, this authorization expires on: (date) not to exceed one year of signature date.
Signature: Date:
Printed Name: Phone #:
Relationship to consumer: ☐ Self ☐ Parent ☐ Legal Guardian ☐ Other:
Witness Signature: Date:
Administrative Use Only
****Note: This authorization to use and disclose information was revoked on ____________________ (Date) ****
I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient
Records, 42 C.F.R. Part 2, and cannot be disclosed without my separate, SUD written consent unless otherwise provided for in the regulations. I understand if I
authorize disclosure of my protected health information to someone who is not covered by confidentiality laws, for example, a family member, it is possible that my
information may be re-disclosed by that person to someone else.
ADDITIONAL DOCUMENTATION REQUIRED FOR SUBSTANCE USE CONSENT. Refer to the “Consent for Disclosure of SUD
Records” form.
I, _________________________________________, authorize the use/disclosure/exchange of information in my medical record relating to
acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV) _____ (initials) and/or
genetic information _____ (initials).
