• Release of Information

    Authorization to use and disclose confidential protected health information

  • Patient Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please check one or more of the following*

  • Person/Entity Information

  • I hereby authorize Alivation Health, LLC to provide and receive information to the following person or entity:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • The Details of this Request are as follows:

  • Purpose of request*
  • What is the purpose for the transfer of care?*
  • I request my records be provided by the following means*
  • Please check the dates of records to be disclosed*
  • From Date: *
     - -
    2 digit month, 2 digit day, 4 digit year
  • To Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Amount of information to be disclosed*

  • Expiration Date: I understand that this authorization shall be in force and effect until   *  (state the specific expiration date or the event triggering the expiration) at which point the authorization will expire.

  • Drug and/or Alcohol Abuse, and/or Psychiatric and Communicable-Non-communicable Diseases: 

  • I understand my records may contain information regarding the diagnosis or treatment of HIV (AIDS virus), or other sexually transmitted diseases (such as hepatitis, gonorrhea), psychiatric care, drug and alcohol abuse/treatment, or other sensitive information. I agree to its release.*

  • Action(s) Requested

  • Check below what you would like Alivation Health to do with this request:

  • Authorizations

  • Revocation of Authorization: I understand that I may revoke this authorization at any time by sending written notification to Alivation Health, 8550 Cuthills Circle Lincoln, NE 68526. I understand that a revocation is not effective to the extent that the providing organization has relied on the authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.


    Authorization for Marketing: I understand that the authorized use or disclosure will result in a direct or indirect payment to the providing organization from a third party. (This section is necessary only if the authorization is for marketing purposes and involves direct or indirect payment to the covered entity from a third party).

    Conditioning of Authorization: I understand that the providing organization will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits on me providing an authorization for the request use or disclosure. Unless my treatment is 1) related to the research, 2) my health care services are provided solely for creating protected health information for disclosure to a third party,or 3) if the authorization is sought for a health plan to determine eligibility or enrollment for underwriting purposes.

  • Signature of patient/ Legal guardian*
  • Date signed*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Note: If submit button is not working, required information is not filled out. 

    Please scroll up to double check your information. 

  • 8550 Cuthills Circle Lincoln, NE 68526 | alivation.com | info@alivation.com 

    Behavioral Health | Phone: 402.476.6060 | Fax: 402.476.6809

    Primary Care | Phone: 402.466.3355 | Fax: 402.466.3410

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