CENTRAL VIRGINIA COMMUNITY SERVICES Lynchburg, Virginia
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
[1] I, ______authorize:
[Print Full Name of Person(s) Authorizing Release of Protected Health Information]
[2] Name of person, title, organization:______Address:______to disclose to:
[3] Name of person, title, organization:______
Address:______
[4] the information specified below concerning the confinement or treatment of:
______
[Print Client’s Full Name, Date of Birth, and Social Security Number]
[5] on the following date(s):______
[Date(s) of Service / Treatment]
[6] Information to be disclosed [check all that apply] :
ÿ Diagnosis ÿ Medication Record(s) ÿ Billing / Insurance Information
ÿ Assessments ÿ History & Physical Examination Report ÿ Other specify]:______
ÿ Progress Notes ÿ Discharge / Transition Summary ______
[7] Disclosure may include [check all that apply]: ÿ Alcohol and/or Drug Abuse Information ÿ AIDS or HIV related information
ÿ Other Infectious Diseases (such as TB, Hepatitis, etc.)
[8] Purpose of disclosure: ÿ Evaluation for services in this Agency ÿ For treatment in this Agency ÿ Other [specify]:______
______
[9] As the person signing this Authorization for Release of Protected Health Information, I understand that I am giving permission for Central Virginia Community Services to release or to obtain and use confidential health information. No threat or other coercive measures have induced me to sign this form; treatment, payment, enrollment or eligibility for benefits is not affected by signing this form. I may refuse to sign this Authorization. I also understand that the information disclosed may be subject to redisclosure by the recipient and may no longer be protected by state or federal law Federal Privacy regulations except as provided by Federal Regulations (42 CFR Part 2). A copy of this Authorization will be included in the client’s service (medical) record.
[10] I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken in reliance on it. I will notify Central Virginia Community Services in writing of my desire to revoke this Authorization; my revocation is not effective until delivered in writing to the person in possession of the client’s medical records. This Authorization will automatically expire upon termination of service in the Agency. Unless otherwise revoked, this Authorization will expire one (1) year from the date specified. or, on the date, event or condition described as:______
______
______
[Client’s / Representative’s Signature] ** [Date]
** Authorization must be signed by the Client; if the signature is not that of the Client, check one of the following: ÿ Client is a Minor
ÿ Client is unable to sign for the following reason(s):______
Basis of Representative’s authority to sign Authorization on behalf of the Client: ______
______
[Staff Witness to Signature] [ Date]
Note: This information may be protected by Federal Regulations (42 CFR Part 2) which prohibit the a recipient from making any further disclosure of this alcohol or substance abuse treatment information unless further disclosure is expressly permitted by written authorization of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for release of medical or other information is NOT sufficient for this purpose. These Federal Regulations also restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.