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614-388-8008
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[email protected]
request an appointment
Standard Authorization Form (Form A & B)
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.
FORM A - AUTHORIZATION FOR RELEASE OF INFORMATION FROM COVERED ENTITIES (OTHER THAN PART 2 PROGRAMS)
Section I
Name
First
Middle
Last
Date
MM slash DD slash YYYY
Social Security Number
Address
City
State
Zip Code
Consent
I hereby authorize the disclosure of health information about the above individual as follows.
Section II
Disclosing Entity ((Covered Entity such as health plan/insurer or provider))
Address
Telephone Number
City
State
Zip Code
Recipient (Person or Entity)
Contact Information (e.g. telephone number, email address, fax number, street address, etc.)
Section III
Reason for Disclosure
Health information to be disclosed
Specify time period, if desired:
Section IV
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 If this authorization has not been revoked, it will expire on the date or completion of the event stated below.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 Individual
Date
MM slash DD slash YYYY
Signature of Personal Representative (if applicable) (Identify relationship to individual below)
Date
MM slash DD slash YYYY
Relationship of Personal Representative to Individual ( Personal representative shall submit proof of authority to the disclosing entity)
Parent
Legal Guardian
Healthcare Power of Attorney
Executor/Administrator
Other
N/A
For administrative use only
Date Released
MM slash DD slash YYYY
FORM B - CONSENT FOR RELEASE OF PART 2 PROGRAM (SUBSTANCE USE DISORDER PROVIDER) INFORMATION
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
Section I
Name
First
Middle
Last
Date of Birth
MM slash DD slash YYYY
Social Security Number
Address
City
State
Zip Code
Consent
I hereby authorize the disclosure of health information about the above individual as follows.
Section II
Disclosing Entity (Name of Holder of Part 2 Program Information) )
Telephone Number
Address
City
State
Zip Code
The information is to be provided to the following:
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.)
Section III
Reason for Disclosure
Health information to be disclosed
Specify time period, if desired:
Section IV
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 Individual
Date
MM slash DD slash YYYY
Signature of Personal Representative (if applicable) (Identify relationship to individual below)
Date
MM slash DD slash YYYY
Relationship of Personal Representative to Individual ( Personal representative shall submit proof of authority to the disclosing entity)
Parent
Legal Guardian
Healthcare Power of Attorney
Executor/Administrator
Other
N/A
For administrative use only
Date Released
MM slash DD slash YYYY
