RELEASE OF INFORMATION - True North Recovery

Office & Mailing Address
591 S. Knik Goose Bay Rd
Wasilla, AK 99654

Office - 907-313-1333 | Fax - 907-357-8781

Consent For Release of Information

By Checking The Box Below I Give My Authorization:*

I, NAMED BELOW, REQUEST/AUTHORIZE TRUE NORTH RECOVERY INC. TO DISCLOSE INFORMATION TO AND/OR OBTAIN MY MEDICAL INFORMATION:

Name*

First Last

Birth Date:*

By Checking The Box Below I Give My Authorization:*

I REQUEST/AUTHORIZE TRUE NORTH RECOVERY INC. TO DISCLOSE INFORMATION TO AND/OR OBTAIN INFORMATION FROM:

NAME OF ORGANIZATION AND/OR INDIVIDUAL

Mailing Address:*

Street Address City State ZIP Code

Email

Phone

Fax

By Checking The Box Below I Give My Authorization:*

I Authorize the following individual / organization to release and/or disclosure of the following clinical treatment records:

Check All That Apply:*

I Consent To Release Records For:*

All Dates of Services
A Specific Date Range

Beginning Date*

Ending Date*

By Checking The Box Below I Give My Authorization:*

To Release Clinical Treatment Records For The Purpose Of:

Check All That Apply:*

Select All
FURTHER TREATMENT/COORDINATION OF CARE AT THE REQUEST OF THE CLIENT
LEGAL PURPOSES
FINANCIAL
PAYMENT HEALTH CARE OPERATIONS
OTHER

This ROI expires one year from the date is was signed, unless it is rescinded below.

By Checking The Box Below I Give My Authorization:*

I UNDERSTAND THAT THE INFORMATION IN THIS HEALTH RECORD MAY CONTAIN INFORMATION RELATING TO SUBSTANCE USE DIAGNOSIS AND/OR TREATMENT, MENTAL HELTH DIAGNOSIS AND/OR TREATMENT AND/OR HUMAN IMMUNODEFICIENCY VIRIUS (HIV) AND AQUIRED IMMUNE DEFICIENCT SYNDROME (AIDS)

Check to Agree:*

I READ THIS ENTIRE CONSENT HAVE BEEN PROVIDED WITH A COPY OF MY RIGHTS UNDER 42 CFR PART 2 AND RESPONSIBILITIES AND UNDERSTAND THE PURPOSE OF THIS CONSENT.

Signature of Client*

Type Name*

First Last

Date*

Signature of Parent / Guardian / Representative

Type Name

First Last

Date

Signature of Witness

Type Name

First Last

Date

STOP

ONLY SIGN BELOW IF YOU ARE WANTING TO RESCIND YOUR ORIGINAL AUTHORIZATION FOR RELEASE OF INFORMATION. IF YOU WISH TO CHANGE THE INFORMATION TO BE RELEASE YOU WILL NEED TO SIGN A NEW ROI.

Signature of Client

Type Name

First Last

Date

PLEASE READ THE FOLLOWING INFORMATION PRIOR TO SIGNING A CONSENT TO RELEASE INFORMATION:

I UNDERSTAND THAT MY ALCOHOL AND/OR DRUG 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 AND ACCOUNTABILITY ACT OF 1996 (“HIPAA”), 45 C.F.R. PTS 160 AND 164, AND CANNOT BE DISCLOSED WITHOUT MY WRITTEN CONSENT UNLESS OTHERWISE PROVIDED FOR BY THE REGULATIONS.

I UNDERSTAND THAT I MAY BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR THE PURPOSES OF TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS, IF ALLOWED BY STATE LAW. I WILL NOT BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR OTHER PURPOSES.

I HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THIS REQUEST/AUTHORIZATION TO RELEASE AND/OR OBTAIN RECORDS AND INFORMATION, INCLUDING THE NATURE OF THE RECORDS, THEIR CONTENTS, AND THE CONSEQUENCES AND IMPLICATIONS OF THEIR RELEASE. I UNDERSTAND THAT ONCE MY INFORMATION IS RELEASED, TNR CANNOT PREVENT THE REDISCLOSURE OF THAT INFORMATION, HOWEVER DOES PROVIDE A STATEMENT OF PROHIBITION AGAINST REDISCLOSURE OF PROTECTED HEALTH INFORMATION WITH DISCLOSURES MADE.

I UNDERSTAND THAT I MAY REVOKE A CONSENT IN WRITING AT ANY TIME, EXCEPT TO THE EXTENT THAT ACTION BASED ON THIS CONSENT HAS ALREADY BEEN TAKEN. SEE RECEPTION FOR INSTRUCTIONS TO REVOKE A CONSENT. IF TREATMENT IS MANDATED AS PART OF PROBATION REQUIREMENTS, A CONSENT MAY NOT BE REVOKED UNTIL CONDITIONS OF PROBATION ARE MET OR PROBATION ENDS.

I HAVE A RIGHT TO RECEIVE A COPY OF THIS SIGNED AUTHORIZATION. I ALSO UNDERSTAND THAT UPON MY WRITTEN REQUEST, TNR MUST PROVIDE A RECORD OF DISCLOSURES MADE FOR LEGAL, ADMINISTRATIVE OR QUALITY ASSURANCE PURPOSES.

NOTICE:

PROHIBITING REDISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION

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 INFORMATION IN THIS RECORD THAT IDENTIFIES A PATIENT AS HAVING OR HAVING HAD A SUBSTANCE USE DISORDER EITHER DIRECTLY, BY REFERENCE TO PUBLICLY AVAILABLE INFORMATION, OR THROUGH VERIFICATION OF SUCH IDENTIFICATION BY ANOTHER PERSON UNLESS FURTHER DISCLOSURE IS EXPRESSLY PERMITTED BY THE WRITTEN CONSENT OF THE INDIVIDUAL WHOSE INFORMATION IS BEING DISCLOSED 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 (SEE § 2.31). THE FEDERAL RULES RESTRICT ANY USE OF THE INFORMATION TO INVESTIGATE OR PROSECUTE WITH REGARD TO A CRIME ANY PATIENT WITH A SUBSTANCE USE DISORDER, EXCEPT AS PROVIDED AT §§ 2.12(C)(5) AND 2.65.

Signature*

Type Name*

First Last

Date*

Release of Information Form

Office & Mailing Address 591 S. Knik Goose Bay Rd Wasilla, AK 99654 Office - 907-313-1333 | Fax - 907-357-8781

Office & Mailing Address
591 S. Knik Goose Bay Rd
Wasilla, AK 99654

Office - 907-313-1333 | Fax - 907-357-8781