Release of Information to Individual

Consent to Individual Recipient

This consent is for family members, friends, etc. who you would like to have access to your health care information.
Name of Individual/s *
Relationship to Patient
Address of Individual/s *

Street Address

Street Address Line 2

City State

Postal / Zip Code
Phone Number of Individual *

Area Code Phone Number
Fax Number of Individual

Area Code Phone Number
For the Purpose of: *
Describe the purpose of disclosure, be as specific as possible.
Dates Range of Disclosure *
Nature of Information to be Disclosed *

Compliance / Attendance with Program Blood / Lab Results (excluding HIV/STIs) Urine Drug Testing Results Verification of Funding Sources Treatment Plan
Describe how much and what kind of information may be disclosed, including an explicit description of what substances use disorder information may be disclosed; as limited as possible.
I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. The Federal rules prohibit 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. I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:
Describe date, event, or condition upon which consent will expire, which must be no longer than reasonably necessary to serve the purpose of this consent
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I have been provided a copy of this form.
Patient Signature: *

Clear
Dated: *

Month Day Year
Date
This information has been disclosed to you from records 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.

Copyright © 2016 Ideal Option PLLC, All Rights Reserved

Revised 06/06/19
Should be Empty:

Consent to Individual Recipient