THE ADANTA GROUP
AUTHORIZATION FOR RELEASE OF INFORMATION
TO RELEASE INFORMATION FROM THE MEDICAL (HEALTH) RECORD OF:
Name: I.D.#: - -
Birth Date:
Information Released From: Information
Released To:
(Person-Relationship/Agency) (Person-Relationship/Agency)
Address: Address:
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Information Released From: (X out if not used) Information
Released To: (X out if not used)
(Person-Relationship/Agency) (Person-Relationship/Agency)
Address: Address:
SPECIFIC INFORMATION TO BE RELEASED: (Client/Guardian to initial all that apply)
________ Biopsychosocial/Assessment/Health Screening _______ Treatment Plan
_______ Progress Notes _______ Psychiatric Evaluation _______ Psychological
_______
Medication Follow-up Sheet ________Discharge Summary ______ History &
Physical
_______ Treatment Information which may include Human
Immunodeficiency Virus (HIV)
Infection, Acquired Immunodeficiency Syndrome (AIDS), or Test for HIV.
________Drug,
Alcohol Treatment Information
________Other (MUST BE SPECIFIC):
____________________________________________________________________________________
AMOUNT OF INFORMATION TO BE RELEASED: (Check box that applies)
____ Information covering the most
recent admission ____ Information
from the beginning to present
____Information covering the
previous three months ____ Other
time frames (Specify): ______ ______________________________
PURPOSE FOR RELEASE: (Check all that apply)
_____Report client’s progress _____ To obtain collateral information in treatment of this client
_____To plan client’s care and treatment _____Verify client’s attendance
_____Other (Specify):
It is understood that this authorization for release
is subject to written revocation at any time, and that unless another date is
specified this release will expire sixty (60) days after date it is signed
(Insert applicable event or date – mm-dd-yy).
TIME LIMITATION OF RELEASE:
Reason for Extension:
Approved: Yes No Approved By:
Medical Record Staff Date
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PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. FEDERAL REGULATIONS (42 CFR PART 2) prohibit you from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR PART 2. The 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.
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The undersigned hereby authorizes and gives this consent voluntarily. I understand that I have a right to inspect the information being released as permitted under the Privacy Rules. I also understand that the provision of services is not contingent on my decision concerning this release of information, unless I am receiving treatment/services solely for the purpose of creating information for disclosure to a third party or if I am receiving research related treatment.
I understand that the Provider cannot guarantee that the Recipient will not re-disclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information.
I understand that I may revoke this Authorization in writing at any time, except that the revocation will not have any effect on any action taken by the Provider in reliance on this Authorization before written notice of revocation is received by the Provider.