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Fields marked with an asterisk (*) are required to be completed. Failure to provide additional identifying information in Section | may result in the inability to respond to this request. This form is not a patient access request under 45 CFR 164.524. Records released pursuant to this authorization may include information concerning testing, diagnosis or treatment of HIV/AIDS, psychiatric and/or drug/alcohol treatment, and/or sexual assault.
First Middle Last
Date MM slash DD slash YYYY Social Security NumberAddress City State Zip Code
I hereby authorize the disclosure of health information about the above individual as follows.
Disclosing Entity ((Covered Entity such as health plan/insurer or provider)) Address Telephone NumberCity State Zip Code Recipient (Person or Entity) Contact Information (e.g. telephone number, email address, fax number, street address, etc.)
Reason for Disclosure Health information to be disclosed Specify time period, if desired:
This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at any time by submitting written revocation in the manner specified by the disclosing entity, except to the extent that action has been taken in rellance on this authorization. If this authorization has not been revoked, it will expire on the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year.Expiration Date or Event MM slash DD slash YYYY • I understand that I may not be denied treatment, payment, and enrollment in the health plan, or eligibility for benefits for for refusing to authorize disclosure unless such denial is permitted under state and federal law. • I understand that information disclosed by this authorization, except as prohibited by 42 CFR Part 2 or other applicable law, may be subject to re-disclosure by the recipient and may no longer be protected by Health Insurance Portability and Accountability Act Rule [42 CFR Part 164].Signature of IndividualDate MM slash DD slash YYYY Signature of Personal Representative (if applicable) (Identify relationship to individual below)Date MM slash DD slash YYYY
Parent Legal Guardian Healthcare Power of Attorney Executor/Administrator Other N/A
For administrative use only Date Released MM slash DD slash YYYY
A Part 2 Program is a federally assisted: (i) individual or entity other than a general medical facility who holds itself out as providing, and provides, substance use disorder (SUD) diagnosis, treatment, or referral for treatment; (i) an identified unit within a general medical facility that holds itself out as providing, and provides, SUD diagnosis, treatment, or referral for treatment; or, (li) medical personnel or staff in a general medical facility whose primary function is provision of SUD diagnosis, treatment, or referral for treatment, and who are identified as such providers
Date of Birth MM slash DD slash YYYY Social Security NumberAddress City State Zip Code
Disclosing Entity (Name of Holder of Part 2 Program Information) ) Telephone NumberAddress City State Zip Code
Named individual Named Third Party Payer Named Treatment Provider Entity Named Non-Treatment Provider (such as an intermediary or research entity)
a. Named Individual Participant(s) b. Named Treatment Provider Entity Participant(s) c. Description of Group or Class of Treatment Provider Entity Participant(s) Contact Information (e.g. telephone number, email address, fax number, street address, etc.)
This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at any time by submitting written revocation in the manner specified by the disclosing entity, except to the extent that action has been taken in rellance on this authorization. If this authorization has not been revoked, it will expire on the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year.Expiration Date or Event MM slash DD slash YYYY • Substance use disorder records of Part 2 programs disclosed pursuant to this Consent are protected by federal regulations and cannot be redisclosed without my written consent unless otherwise provided for in the regulations. Any information disclosed pursuant to this Consent other than substance use disorder records or records protected under another state law may be subject to re-disclosure by the recipient. • I might be denied services if I refuse to authorize disclosure of information for purposes of assessment, treatment, or payment relating substance use disorder if refusal is permitted by state law. My refusal to authorize disclosure of information for other purposes will not affect my ability to obtain treatment or services. • If I have authorized disclosure to a generally described group or class of participants in an entity which is not my treatment provider, upon my written request, I must be provided a list of entities to which my information has been disclosed pursuant to that general designation.Signature of IndividualDate MM slash DD slash YYYY Signature of Personal Representative (if applicable) (Identify relationship to individual below)Date MM slash DD slash YYYY