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AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
I hereby authorize use or disclosure of protected health information about me as described below.
1. The following specific person/class of person/facility is authorized to use or disclose information about me:
2. The following person (or class of persons) may receive disclosure of protected health information about me:
3. The specific information that should be disclosed is (please give dates of service if possible):
UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED:
YES, DISCLOSE THIS INFORMATION *____________________________________________________________________
NO, DO NOT DISCLOSE THIS INFORMATION * _____________________________________________________________
4. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
5. I may revoke this authorization by notifying _______________________________ in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
6. My purpose/use of the information is for ___________________________________________________________________________ .
7. This authorization expires on _____________, 200___, OR upon occurrence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me: _____________________________________.
FEES FOR COPIES: Federal and state laws permit a fee to be charged for the copying of patient records. You may be required to pre-pay for the copies; if not, then your copies will be mailed along with an invoice.
THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING – note that signature is required in two places.*
OR, if applicable –
A copy of this completed, signed and dated form must be given to the Individual or other signatory.