Authorization for Release of Confidential Information

DOB

Client ID #

Admission Date

hereby authorize Adult Youth Services, LLC., to release confidential information to and receive form the name or organizations listed below:

Name/Title of Organization:

Relationship to Client

Address:

Alcohol/drug History

Treatment discharge summary

Probation/parole history and reports

Assessmenuevaluation report

Alcohol/drug abuse treatment

Family history/social information

Consultation reports

Medical history/treatment summary

Personnel report/job performance

Progress/compliance report

Psychiatric history/treatment summary/evaluation

Cost of treatment

TMS

Attendance

Other (Specifiy)

I also understand that this information communicated in a variety of ways, such as verbally, in writting or a facsmile trensmission.

To facilitate alcohol/drug treatment

To provide follow-up information

To arrange transfer to other treatment

To coordinate medical care

Comply w/probation/parole conditions

Inform relative/friend of treatment status

To meet terms of employment

To provide information for legal action

Payment arrangement only

Other: (Specify)

I understand that information regarding my alcohol and/or drug treatment is protected by federal law under the Drug Abuse Prevention, Treatment and Rehabilitations Act and the privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPPA), and their implementing regulations. See generally 42 C.F.R. Part 2; 45 C.F.R. Parts 160, 164. I understand that my health information specified above will be disclosed pursuant to this authorization that the recipient of the information may re-disclose the information and it may no longer be protected by federal law under Hipper. Federal law governing confidentiality of alcohol and drug abuse patient information, noted above. However, will continue to be protect the confidentiality of information that identifies me as a patient, legal guardian, or parent in an alcohol or there drug program from re-disclosure. I understand that this consent will remain in effect and may be revoke by me, legal guardian or parent at any time in writing: date. There is an exception to the extent that action has been taken in reliance, and that this consent will expire in two (2) years unless otherwise specified .Date

CLIENT SIGNATURE

DATE:

This information has oeen disclosed to you from records whose confidentiality is protected by federal law. Federal law see (42 C.F.R. Part 2) proibit you formiraking any further disclosure of it without specific written consent of the person to whom it pertains, or as otherwise permitted by such regulation A general authorization for the release of information is not sufficient for this purpose. This authorization for release of information may be considered an as original in instances of fax or electronic transmittal.

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