Authorization for Disclosure of Protected Health Information

Instructions: Fill out each section of the form in its entirely. Failure to do so may delay processing of your request.
Patient Information
Patient Name*
First Middle Initial Last
Date of Birth*
Address*
Street Address Apartment/Unit # City State ZIP Code
Maiden/Previous Names:
Email*
Phone Number*

I AUTHORIZE RELEASE OF ALL ALCOHOL AND / OR DRUG TREATMENT RECORDS THAT ARE PART OF THE RECORDS I SPECIFIED ABOVE UNLESS OTHERWISE INDICATED BELOW:
- Do not release alcohol or drug treatment records protected under federal law
I may revoke this authorization at any time by sending written notice to the facility/provider releasing records. A revocation is not valid if (1) action was previously taken in reliance on this authorization, or (2) if this authorization was obtained as a condition for obtaining insurance coverage. I authorize the facility/provider to disclose medical information to the party identified in the “Release Information To” section. I understand this may include information regarding mental health, alcohol/drug use, and HIV treatment. I understand that once disclosed, information may be re-disclosed by the recipient and no longer protected. I understand this authorization is voluntary and that I may refuse to sign. Unless allowed by law, my refusal to sign will not affect my ability to obtain treatment, receive payment, or my eligibility for benefits.
Signature*
Your Name
Your Name
Your Name
Date*
Time*

: Hours

Minutes

AM/PM
Relationship of Person Signing (If not the Patient)

Patient Information