• Authorization to Release and Disclose Patient Information

    Authorization to Release and Disclose Patient Information

  • Release Information From:

    Riverwood Healthcare Center

    200 Bunker Hill Drive

    Aitkin, MN 56431

    Phone: 218-927-2121

    Fax: 218-927-5319

     

  • What are the approximate service dates of information being released?
    Between * to *

  • All information regarding chemical dependency or behavioral health will be released unless you restrict by initialing below:
    Do not release chemical dependency information
    Do not release behavioral health information

  • I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.
    I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization expires once the above stated purpose is fulfilled or one year, whichever comes first.

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  • Authority to act on behalf of patient (if not on file, attach document below)

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