Authorization to Send, Receive and/or Exchange Healthcare Information

Authorization to Send, Receive and/or Exchange Healthcare Information
This Release of Information (ROI) applies to all Health Solutions programs and locations, including behavioral health, substance use disorder services, and primary care services.
Client Information
Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize Health Solutions to use and disclose my protected health information, including substance use disorder (SUD) records protected under 42 CFR Part 2, as described in this authorization. This authorization permits disclosure to individual(s), organization(s), or class of recipients listed below and, unless otherwise limited by me, permits disclosure to HIPAA-covered entities and business associates for purposes of treatment, payment, and health care operations (TPO).

This authorization allows two-way communication between Health Solutions and the listed party.
To be released to/from:
Name of Individual or Organization (External Agency)*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Continuity/Transition of Care PacketPhysician Orders and EvaluationsClinical Assessment and Treatment PlanLab/Diagnostic ReportsHIV/AIDS Results and TreatmentAppointment StatusDischarge SummaryProgress NotesOther
I agree to the use and disclosure of my substance use disorder (SUD) counseling notes. A Part 2 program may not require me to check this box as a condition of treatment, payment, enrollment in a health care plan, or eligibility for benefits. SUD counseling notes may contain detailed information, including but not limited to conversational content, analysis, information about the clients emotional/cognitive state, and specific risks.
Additional Evaluation or TreatmentLegal Proceedings/Court ReportsProfessional ConsultationClient/Guardian RequestObtaining Client Resources or BenefitsTx, Payment or Health Care OperationsContinuity of CareService PlanningOther
Optional: Released information will be relevant to the selected dates only. Note: The exact dates of the documents may fall outside the date range selected
(Optional) from (date)
from (date)

MonthDayYear
Date
to (date)

MonthDayYear
Date
OTHER IMPORTANT INFORMATION

Client Rights: I do not have to sign this document to get treatment at Health Solutions unless treatment is required by a court or another official; I have the right to revoke this authorization in writing; Some information about me may be given out without my consent if the law allows it (see Notice of Privacy Practices); Copies of this form may be used in place of the original; Signatures received by fax will be accepted; Health Solutions cannot promise that people who get this information will keep it private. They may or may not have to follow the privacy laws; I understand that I am entitled to a copy of this authorization; This authorization form applies to all Health Solutions programs and locations, including behavioral health and primary care; SUD Counseling and Psychotherapy Notes may be released at the discretion of the provider. Redisclosure Notice: I understand that if HIPAA and 42 CFR Part 2 covered entities and business associates receive these records for treatment, payment, and healthcare operations purposes, the records may be redisclosed in accordance with HIPAA and 42 CFR Part 2, except for uses or disclosures for civil, criminal, administrative, or legislative proceedings against me.

This authorization will expire two years from signature if not revoked.
PatientAuthorized Personal Representative
I understand the terms of this consent, and my right to obtain information on the disclosure of my record.*

Clear
Date*

MonthDayYear
Date
If signed by a Personal Representative, please state relationship and authority to consent
Revocation

By signing, I withdraw consent for release of my health information to the party or parties named above:
I REVOKE the above

Clear
Should be Empty:

Authorization to Send, Receive and/or Exchange Healthcare Information

Client Information

To be released to/from:

Revocation