CLIENT INFORMATION RELEASE AUTHORIZATION
I, authorize Ten Sixteen Recovery Network and the individuals or organizations listed to have reciprocal communication about the information listed:
Type of disclosure:
I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (?HIPPAA?), 45 CFR Parts 160 & 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 in writing at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
I understand that generally Ten Sixteen Recovery Network may not condition my services on whether I sign a consent form, but that in certain limited circumstances I may be denied treatment if I do not sign a consent form.
Client Signature: Date:
Staff Signature (witnessed by): Date:
This information has been disclosed to you from records protected by federal confidentiality rules (CFR 42, Part 2). The federal rules prohibit you from making any further disclosures 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 CFR42, Part 2. A general authorization for the 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.
Notice sent to: by (name) on (date)
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