Authorization for Release of Information

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Description generated with high confidence

8336 Monroe Rd. Suite 120 Lambertville, MI 48144 Phone: (734) 807-0162 Fax: (888) 700-7159

Authorization for Release of Information

Client Name:_________________________________________________________________________________________________

Client Address:_______________________________________________________________________________________________

Date Of Birth:___________________________________________SSN:_________________________________________________

Hereby authorize Bedford Behavioral Health, 8336 Monroe Rd. Ste. 120 Lambertville, MI 48144

to obtain records from to disclose records to

Person/Entity Name:__________________________________________Address:_____________________________________________________

Information to be used or disclosed includes only those items checked below with respect to services provided on or around (insert dates of service):__________________. If this is left blank, the treatment dates covered by this authorization are the date of intake to the last date of service.

I understand that this authorization extends to all or any part of the records/information designated below. This information to be used or released includes:

Dates of Service Intake Information Treatment plans Psychological testing

Progress Notes Billing/Financial Records School Records Medical Records

HIV/AIDS Information____ (must initial) Drug & Alcohol Information______(must initial)

other:_______________________________________________________________________

This authorization is limited to only that information that is being requested above is to be used or disclosed to the person/entities named herein. I hereby release Bedford Behavioral Health from all legal responsibilities or liability that may arise from the use or disclosure of medical records and other health information in reference on this authorization.

  • Expiration: I understand that unless I revoke this authorization earlier, this authorization will automatically expire 180 days, or according to the relevant state or federal law, from the date this authorization is signed.
  • Re-Disclosure: I understand that information used or disclosed in accordance with this authorization may no longer by protected by federal law and could be used or re-disclosed by the receiving party.
  • Refusal to sign: I understand that I may refuse to sign this authorization and that the Bedford Behavioral Health Counselor will not condition treatment on whether I sign this authorization.
  • Revocation: I have the right to stop the use or release of information at any time, although I understand that I cannot so anything about information already used or disclosed under this authorization.
  • Copy: I understand that I will receive a copy of this completed form upon request.

____________________________________________________________________________________________________________

Signature of Client/Guardian

____________________________________________________________________________________________________________

Signature of Witness

FOR THE RECIPIENT OF THE INFORMATION: If any of the requested records contain information regarding alcohol or drug abuse treatment, it may be protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further use or 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 use or 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. (Prohibition on Redisclosure,2004).