I authorize Ideal Option, PLLC to disclose to any third-party payor all necessary information and relevant portions of my patient record for the purpose of receiving payment for services rendered.
I authorize Ideal Option, PLLC to disclose to any third-party payor all necessary identifying demographic information for the purpose of protecting against an existing threat to life or of serious bodily injury, including circumstances
which constitute suspected child abuse and neglect and verbal threats against third parties.
I understand that my alcohol/drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations.
I also understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it (including the provision of treatment services in reliance on a valid consent to disclose information to a third party payer), and that in any event this consent expires 365 days after my deactivation from Ideal Option as a patient or as otherwise follows: