Updated 8/20
LoGrasso Hall, Fredonia, NY 14063
T: (716) 673- 3424 F: (716) 673-3140
Authorization for the Disclosure and Exchange of Protected Health Information
I, _____________________________________, __________________/_____________, hereby give permission
Client Student ID # Date of Birth
Name of agency, individual or position (e.g. attorney, school counselor, therapist)
Address City State Zip Code
_______________________________________ __________________________________________
Phone Fax
Form in Which Information Should be Released
Oral Photocopy Fax
Other (specify): _____________________________________
Information to be Disclosed
My mental health record in its entirety; or My substance abuse record in its entirety; or
Only the following information (client must initial each item to be released):
____________substance abuse evaluation __________________treatment summary
____________treatment recommendations __________________psychiatric evaluation
____________attendance records only __________________diagnosis/assessment
____________other (specify )_____________________________________________________________
Purpose for Disclosure
To permit coordination & collaboration of care Transfer of services
To permit continuity of care Consultation
Other: _______________________________________
At any time, I may revoke this consent orally or in writing. I understand that the revocation will not be
effective retroactively for information exchanges that have already occurred. Unless otherwise noted, this
consent expires one (1) year from the date of my signature below. I agree that a photocopy of this release
shall be as valid as the original.
I understand that my authorization, or refusal, will not affect my ability to receive treatment.
I understand that the potential exists for re-disclosure of my private mental health information by the
recipient, and such information is no longer protected by federal health information privacy regulations.
Signature of client:________________________________________________________ Date: _____________
Witness:_________________________________________________________________ Date:______________
Notice to Recipient of Information
This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. If
the records are so protected, Federal Regulation (42CFR Part 2) prohibits you from making any further disclosure of this information
unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, 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. The Federal
rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.
click to sign
click to edit
click to sign
click to edit