AUTHORIZATION FOR USE AND

DISCLOSURE OF INFORMATION

Name of Client______________________________________________________

Date of Birth:____________ Phone #__________________________

I authorize: To release to:

___________________________________________ _______________________________________

___________________________________________ _______________________________________

___________________________________________ _______________________________________

SPECIFIC DESCRIPTION OF INFORMATION TO BE USED AND DISCLOSED

(specify dates for each, unless “entire medical record” is selected)

_____ Treatment from ______________(date) to _______________(date)

______Hospital Admission Summary ______Lab Reports ______Pathology Report

______Entire Medical Record for all dates ______

______Progress Notes/Clinic Notes ______Psychiatric Intake ______Operative Report

______Other (please specify)___________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

􀂆 Verbal discussion only – do not release any written records

I AUTHORIZE RELEASE OF ALL ALCOHOL AND/OR DRUG ABUSE RECORDS THAT ARE PART

OF THE RECORDS I SPECIFIED ABOVE, UNLESS OTHERWISE INDICATED HERE:

___Do not release records from alcohol or drug abuse treatment programs that are protected under federal law.

PURPOSE OF THE USE AND DISCLOSURE

_____Further Treatment (Date of Appointment________________) _____Insurance Application

_____Personal Records _____Education _____Disability Determination

_____Vocational Rehabilitation Evaluation _____At my request _____Payment of Insurance Claims

_____Legal _____Other ________________________________________________

I authorize the use and disclosure of my individually identifiable health information as described above, including

verbal and written exchanges about the information unless I indicated otherwise. I understand that this authorization is voluntary. I understand that if the person or organization I authorize to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and could be re-disclosed. I understand that my health care and payment for my health care will not be affected if I do not sign this form.

I understand that I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it. I understand that this authorization will expire on: _______________ (specify date or event) or, if no date or event is specified, 12 months from the date of signing.

A photocopy or fax of this authorization will be treated in the same manner as the original.

____________________________________________________ __________________________

Signature of Patient/Guardian/Representative Date

____________________________________________________

(If not patient, state authority/relationship)

Authorization for Use and Disclosure of Information Kathleen Baxa/ Brianna Sorensen