Authorization of Disclosure Client Name* First Last Suffix DOB* Month Day Year SSN* Email I authorize* to:* Disclose to Receive from Name PhoneFaxAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information to be Disclosed* Select All Discharge Summary Treatment Plan Psychological Testing Psychological Evaluations Family Assessment Verbal/Written Communication Intake Information Progress Notes Psychiatric Assessments Medication Records Other... Verbal/Written Communication with... Describe entity with whom to share information Describe "Other" above I understand that my drug and/or alcohol treatment records are protected under the Federal Regulations governing Confidentiality and Drug Abuse Patient Records (42 C.F.R. Part 2) and the Health Insurance Portability Act (HIPPA) of 1996 (45 C.F.R., Parts 160 and 164) and cannot be disclosed without written consent unless otherwise provided for by the regulations.I understand that by signing this authorization, I am allowing the release of my mental behavioral health information. This may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), other communicable diseases, and/or alcohol/drug abuse.Drug/Alc checkbox Check this box if you wish for Drug/Alcohol Abuse information NOT to be released.Wet Signature: _____________________________________________Date: ______________________You will sign and date this option when you arrive at the office.HIV checkbox Check this box if you wish for HIV information NOT to be released.Wet Signature: _____________________________________________Date: ______________________You will sign and date this option when you arrive at the office.Purpose of Disclosure Evaluation/Treatment Planning Case Coordination Legal Procedings School Placement or Assessment At Client's Request Other Specify "Other" for Purpose of Disclosure Effective Date*This authorization becomes effective on date specified and will automatically expire one year from the date of request or sooner as designated. MM slash DD slash YYYY Sooner Expiration Date MM slash DD slash YYYY I understand that I have a right to revoke this authorization at any time. I must do so in writing and present my written revocation at the office where I am being seen. I further understand that actions already taken based on this authorization, prior to the revocation, will not be affected. I understand that I have the right to a copy of this authorization. I understand that authorizing the disclosure of this protected health information is voluntary in most cases. I can refuse to sign this authorization. I do not need sign this form to assure treatment. But, I will be refused treatment for my refusal to sign if my care is mandatory by corrections or the Juvenile Justice System.I understand that I may request to inspect or obtain a copy of my record. I understand that any disclosure of information carries the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. Redisclosure may occur in situations such as if my provider’s care is reviewed by a state or federal agency, a court orders the disclosure of information, or if I sue my provider and my provider needs the information to defend himself/herself. If I have questions about disclosure of my protected health information, I can contact the office manager at Stonestreet Professional Offices. PROHIBITION ON REDISCLOSURE OF ALCOHOL AND/OR DRUG ABUSE TREATMENT INFORMATION RECORDS: This information has been disclosed to you from records where confidentiality is protected by Federal law. Federal regulations (42 C.F.R., Part 2) prohibit you from making further disclosure of it without the specific written authorization of the person to whom it pertains, or as otherwise specified by such regulations. A general authorization for disclosure of medical or other information is NOT sufficient for this purpose.Consent I have read and understand this form. I am the client listed or am authorized to act on behalf of the client as the client’s personal representative. I also permit the disclosures indicated above upon presentation of a photocopy of this authorization.Check the box to confirm your consent.___________________________________________________________ Signature of Client or Parent/Legal Guardian/Representative___________________________________________ Date of Signature___________________________________________________________ Witness Signature___________________________________________ Date of SignatureYou and a witness will sign and date this consent document when you arrive at the office.EmailThis field is for validation purposes and should be left unchanged.