GOODWILL IINDUSTRIES OF RHODEISLAND

100 Houghton Street, Providence, RI 02904

Phone: (401) 861-2080 Fax: (401)454-0889

AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

Client Name:

Last four digits of SS#:Date of Birth:

Please select either Send or Obtain (Send means our records are sent. Obtain means we are getting records. Discuss means whether we are sending or obtaining. We can have a two-way conversation with the person/place indicated.

(X)I hereby authorize that Goodwill Industries of Rhode Island Send/Discuss the record of my care to:

(X)I hereby authorize that Goodwill Industries of Rhode Island Obtain/Discuss the record of my care from:

Method of Release:Verbal and Printed MaterialsDates of Service:

Name:Phone Number:

Address:State/Zip

Please select the appropriate information to be released (Yes or No must be selected for each item):

(X)Yes( ) NoAssessment( ) Yes (X) NoTreatment Plan(X) Yes( ) NoEducational Information

( )Yes(X) NoDischarge Summary( ) Yes (X) NoPsychiatric Evaluation( ) Yes(X) NoHistory & Physical PCP

( )Yes(X) NoLaboratory Data( ) Yes (X) NoMedication Profile/HistoryCoordination of Care Form

( )Yes(X) NoLetter(X) Yes ( ) NoVocational( ) Yes(X) NoOther

This information is needed for the following purpose:( ) Client Care(X) Other – Educational/Vocational

I understand that my records are protected under federal confidentiality regulations (42 CFR Part 2), confidentiality of alcohol and drug abuse treatment (if relevant) and The Health Insurance Portability and Accountability Act of 1996. I understand that the information in my health record may relate to treatment for mental health, alcohol or drug abuse, sexual abuse, venereal disease, and/or HIV/AIDS information. I specifically authorize the release of this information. I understand that I may revoke (cancel) this authorization at any time. I must do so, in writing, to Health Information Services. I understand that this revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will no be effective until it is received. I understand that signing this authorization is voluntary and Goodwill Industries of Rhode Island will provide treatment and pursue payment for services regardless of whether I sign this authorization. If, however, my treatment is related to a research study, or solely for the purpose of providing information about my health or medical condition to someone else, Goodwill Industries of Rhode Island may require that I sign this authorization before it provides treatment to me. I understand that if I authorize Goodwill Industries of Rhode island to disclose information, the recipient of the information might disclose it to others, and that any information disclosed by Goodwill Industries may no longer be protected by the federal rules of the privacy of medical records. I further release Goodwill Industries and its employees from any liability arising from the release of this information to such persons/agencies, provided that said release of information is done substantially in accordance with applicable law. Information released with this authorization will not be given, sold, transferred or in any way relayed to any other person or party not specified above, without my further written consent.

This consent will have a duration no longer than 1 (one) year from the date of this form, unless specified.

Specify date (less than one year):

______

Signature of Client or Parent/Legal GuardianRelationship to ClientDate

______If client has a legal guardian or is an emancipated minor, request

Signature of Client under 18copies of the legal documentation.

Signature and Credentials( )Date:

Staff Use Only:Unless indicated, release will be filed:Process( )Staff ID:Date: