Authorization To Disclose Or Obtain Information - Release of Information/Adult/ROI

Authorization to Disclose or Obtain Information - Adult
I (Client's Name),*

First NameLast Name
Whose date of birth is:*

MonthDayYear
Date
Authorize Jewish Family Service of the Desert (JFS) to disclose and/or obtain information to/from*
Their Name*
Their Phone Number*
Please enter a valid phone number.
Their Fax Number
Please enter a valid phone number.
Their Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The following information is to be disclosed:*

AssessmentDiagnosisTreatment Plan or SummaryCurrent Treatment UpdatePresence/Participation in TreatmentEducational InformationDischarge/Transfer SummaryContinuing Care PlanProgress in TreatmentDemographic InformationLegal DocumentsLetterSchedule/Cancel AppointmentsBilling/Financial StatementOther
If "Other" please enter here
Purpose
The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and, when appropriate, coordinate treatment services.
If other purpose, specify:
Revocation
I understand that I have the right to revoke this authorization in writing at any time by sending written notification to JFS at 490 S. Farrell Dr., Suite C208, Palm Springs, CA 92262. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Expiration
Unless sooner revoked, this consent expires three (3) years from the date on the signature/initialed page or as otherwise indicated below
If other date, indicate here

MonthDayYear
Date
Conditions
I further understand that JFS will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the consequences below:
Please enter if any
Form of Disclosure
Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

Re-disclosure
Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R Part 2. Other types of information may be re-disclosed by the recipient of the information in the circumstances below:
Enter circumstances if any
I have read, understand and agree to the JFS Authorization to Disclose or Obtain Information above.*
Client Name

First NameLast Name
Today's Date*

MonthDayYear
Date
Client Signature*

Clear
Should be Empty:

Authorization to Disclose or Obtain Information - Adult