Consent to Release Confidential Information Authorization Form


    Name of patient:

    Phone Number:

    Date of Birth:

    Parent/Guardian Name:

    Address:

    City:

    State:

    Zip Code:


    Organization/Person/Provider information is being released to, or obtained from, by Serenity:

    Address:

    City:

    State:

    Zip Code:

    Email:

    This release of information is active from until .

    Client has the right to revoke at any time, revoke date .

    Client Signature:


    PLEASE INITIAL THE RECORDS THAT YOU WISH TO RELEASE.
    Client has the right to revoke at any time.


    I authorize Serenity Mental Health/Silver State Health toRelease and/orObtain the following information:
     

    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:


    Initial Below to Release:

    My signature authorizes the release of these records through facsimile transmission (FAX).

    I understand and agree that should the records be inadvertently transmitted to an unauthorized recipient, through no fault of the sender, I hereby waive any claim against the sender.

    I agree to hold the sender harmless from any and all responsibility for damages, if any, arising from the faulty transmission.

    This authorization is in effect until termination of treatment or 12 months from the above date.

    I understand that I may change my mind at any time and revoke this authorization by notifying Serenity Mental Health/Silver State Health in writing.

    I understand that changing my mind or refusing to sign this form will not affect my treatment.

    I understand that I have the right to inspect or copy any information disclosed under this authorization.

    I understand that once my health information is disclosed to the recipient, Serenity Mental Health/Silver State Health cannot guarantee that the recipient will not disclose the health information to a third party or as required by law.

    I have read and understand this authorization and had a chance to ask questions about the disclosure of the health information.

    I authorize Serenity Mental Health to disclose my health information in the manner described above.

    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.

    As a client you agree that patient identifying information disclosed pursuant to an audit or evaluation may be disclosed only back to the program from which it was obtained and used only to carry out an audit or evaluation or to investigate or prosecute criminal or other activities as authorized by a court order entered under § 2.66 of the drug treatment confidentiality records contained in 42 C.F.R. Part 2. If I copy or remove any records containing patient identifying information, I also agree to maintain the patient identifying information in accordance with the security requirements contained in 42 C.F.R. § 2.16 and to destroy all patient identifying information upon completion of the audit or evaluation.