Release / Authorization Form

Release / Authorization Form
Patient Name

FirstLast
Date of Birth

MonthDayYear
Other Name(s) Used in Treatment
Phone Number
Email Address
Facility Name
Dates of Service

MonthDayYear
How would you like your record(s) sent?

EmailFaxMail
I authorize Charles River Recovery and its affiliate facilities to communicate with and release my medical record(s) to:
Name
Attention
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Fax Number
Email
Purpose of Release

PersonalVerify AttendanceInsuranceReturn to WorkLegalFMLA/DisabilityTreatment/Continuing Care
Other
Information and records requested may include reference to my HIV/AIDS status.

I do NOT want this included
I understand that my substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2 (SAMSHA) and cannot be disclosed without written consent unless otherwise provided for by the regulations. By signing below, I am knowingly releasing this protected health information.
Patient Signature
Date

MonthDayYear
Parent / Guarding Signature (when required)
Date

MonthDayYear
Landing Page URL
Landing Page URL Last
Referrer URL
Referrer URL Last
Converting URL
Should be Empty:

I authorize Charles River Recovery and its affiliate facilities to communicate with and release my medical record(s) to: