Authorization For Release Of Confidential Information
The purpose of disclosure is for:
I authorize the disclosure of the following information:
This consent is valid for 30 days unless otherwise specified but no longer than one year.
I understand that this information may include information relating to: a. Acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection; b. Recovery support for drug or alcohol abuse; c. Mental, emotional, or behavioral health; d. Psychiatric or medical care.
I understand that any release or disclosure is bound by Title 42 of the Federal Regulations governing the confidentiality of alcohol and drug abuse patient records, as well as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) 45 C.F.R. Pts. 160 & 164; and that redisclosure of this information to a party other than the one designated above is forbidden without additional written authorization on my part. Pursuant to IC 16-39 regarding the release of mental health records and federal confidentiality rules 42-CFR Part 2 regarding the release of addiction information:
- This consent is subject to revocation at any time, except to the extent that action has been taken in reliance on the patient’s consent.
- If not previously revoked, the patient’s consent to release mental health and/or addiction information will expire when this date, event, or condition met occurs: One Year from Date Signed.
- If involuntary commitment to the program, I understand I may not revoke this consent until disposition of my case is complete or if I leave without committing authority’s permission, the committing authority will be notified.
(Signature of client)
(Signature of Parent/Guardian, when required)
NOTICE TO RECEIVER: Any addiction information disclosed to you is protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.