Helix Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information [3793:2-1-06(H)]
Disclose InformationReceive InformationExchange Information
Regarding (Client Name)*

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
Agency: Helix LLC

Attn: Admissions and Medical Records

Location: 1035 W Broadway Ave Minneapolis, MN 55411

Phone: 651-300-0465

Fax: 612-464-7229
Person or Agency Contact Authorized to Disclose/Receive/Exchange Information*
Contact Name
If Applicable, Name of Program Authorized to Disclose/Receive/Exchange Information
Program Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax #
Please enter a valid phone number.
YesNo
Agency Authorized to Release or Receive Information*
Agency Name
Person or Contact Authorized to Release or Receive Information*
Contact Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Care CoordinationOngoing TreamentCollateralDisability DeterminationTreatment PlanningOther
AttendanceCrisis AssessmentLab tests including medication resultsPhysician's Orders/Case NotesPregnancy Test resultsPrenatal Care ReceivedProgress in TreatmentPsychiatric/Mental Health EvaluationPsychological EvaluationInformation on Mental Illness and /or TreatmentUrine TestingComprehensive AssessmentSUD Treatment RecordsOther
Most recent episode of careWithin the past yearOther
I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon Helix LLC's receipt of the written revocation.
This authorization will expire in one year.This authorization will expire upon the termination of services.Other
ClientGuardian/Authorized RepOther
Signature*

Clear
Effective Date*

MonthDayYear
Date
NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION 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 (HIPAA), 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.
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