Consent for Release of Information - Central Behavioral Healthcare

Name

Date of Birth

I hereby authorize:

Option

release to

obtain from

Name of Clinician

Name of Individual & Institution

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Fax

The following information (check all that apply):

Other if not listed above

For dates of service from:

To date:

For the specific purpose of (check all that apply):

Treatment Planning

Assessment

Legal Proceedings

Verify Treatment Participation

Continuing Education

Other if not listed above

I release the above cited individuals or facilities of any legal liability that may arise from the release of the information request. I understand that the agency cannot release information from other resources.
I understand that the individual/institution/agency receiving this information may not re-release it to any other individual, institution or agency.
I understand that this authorization for release of information will automatically expire one year after the date of this release unless otherwise indicated below.*
I understand that this release can be revoked by me at any time and that the revocation must be signed and dated by me.
I understand the information in my health record may include information relating to sexually transmitted disease, tuberculosis (TB), hepatitis B, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
I understand that treatment or payment for services rendered cannot be conditioned on the signing of this authorization, except in the instance of research-related treatment or when the provision of health care to me is solely for the purpose of creating protected health information for disclosure to a third party.

This Consent for Release of Information will expire:

90 days from the date of signature

180 days from the date of signature

Signature

Current Date

Relationship

Witness

Notification of records sent, date and signature

I hereby revoke my consent for the release of the above information. I understand that disclosures made in good faith may have already occurred in reliance upon my previously issued authorization and that this revocation cannot apply retroactively to such disclosures. I also understand that the disclosure of health information may be required by law in some instances, therefore, the facility, its employees, officers, and therapists are hereby released from any legal responsibility or liability for disclosure of the information I previously authorized (fields below will be signed and filled out at a later time).