AUTHORIZATION TO DISCLOSE CLIENT INFORMATION

AUTHORIZATION TO DISCLOSE CLIENT INFORMATION

Release of Information
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
The following programs are authorized to:*
disclose,receive, orexchange information as noted ABOVE.
Authorized Individual/Organization to Whom Disclosure is Made*
Purpose of Disclosure:

to coordinate treatment,to gather assessment information for treatment planning,to gather information for ongoing treatment,
other purposes [specify]
Type of Information to be Disclosed:

progress notes,diagnostic assessment information,progress in treatment,lab results,urine testing,attendance,HIV/AIDS testing or status,pregnancy testing,prenatal care,diagnosis,information on mental illness and/or treatment,
other purposes [specify]
Amount of Information to be Disclosed:

information covering the previous three months,information covering the most recent admission,
other purposes [specify]
This authorization expires 90 Days Post Discharge
Signature and Date of Client or Other Person Authorized to Permit Disclosure*

Clear
Date*

MonthDayYear
Date
Signature and Date of Staff or Witness

Clear
Date

MonthDayYear
Date
Revocation: This authorization is subject to written revocation at any time except to the extent the program or person who is to make the disclosure has already acted in reliance on it.
I hereby revoke consent (Client Signature & Date)

Clear
Date

MonthDayYear
Date
This authorization expires [specify event, date and/or condition]
Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit 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 C.F.R., 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 information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 [HIPPA], 45 C.F.R., parts 160 and 164. [These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.]
Should be Empty: