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Consent for Release of Information (Web)
Community & Family Resources
Phone 515-576-7261
Fax 515-955-7628
Client Information
First Name:
*
Last Name:
*
Date of Birth:
*
Birth Sex:
*
Address:
City:
State:
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Zip Code :
Phone No:
Date
Medicaid #
Medicare #
* I authorize
Community and Family Resources, Inc.
The Richmond Center
* to
disclose & obtain information
disclose information
obtain information
* to/for:
individual's name
* Agency Affiliation:
* the following:
Yes
No
Mental Health
Yes
No
Substance Abuse
Yes
No
Gambling
Yes
No
HIV
* Treatment Information:
Yes
No
My name and other personal identification information
Yes
No
My status as a patient in treatment
Yes
No
Initial and subsequent evaluations of my service needs by the above named organizations/people
Yes
No
Summaries of assessment(s) results and history
Yes
No
Summary of treatment services, progress and compliance
Yes
No
Attendance in treatment services
Yes
No
Discharge plans from treatment services, and discharge status
Yes
No
Drug testing/screening results
Yes
No
Other (specify below)
If other, specify:
* The purpose of the disclosure is to:
facilitate coordination of care
facilitate coordination of care with our healthcare professionals
provide evidence of treatment as required for continued employment
provide evidence of treatment to a protective service agency
I understand that I may revoke this consent at any time, except to the extent that action has already been taken in reliance upon it.
Unless otherwise indicated, this release allows for verbal and written disclosures. Verbal disclosures made to a third party, may lose 42 CFR Part 2 protection if that agency writes the information down in their record and they are not required to follow 42 CFR Part 2 regulations.
A photocopy of this release shall have the same effect as an original. I also understand that generally Community and Family Resources may not condition my treatment on whether I sign a consent form, but in certain limited circumstances, I may be denied treatment if I do not sign a consent for release of confidential information form.
* This consent form expires 180 days from the date of discharge from treatment services and/or on (date/condition). Not to Exceed one year.
* Signature of Client
Signer Type:
Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
Name:
Sign with Touch
Signature of Guardian
Signer Type:
Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
Name:
Sign with Touch
PROHIBITION FOR REDISCLOSURE
This information has been disclosed to you from records whose confidentiality is protected by Federal and/or State law. This Consent for Release of Confidential Information form does not authorize redisclosure of medical information beyond the limits of this consent. Federal Law including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and /or45 C.F.R. parts 160 &164, and/or 42 CFR Part 2 (for alcohol/drug abuse), and/or State Law (Iowa Code Ch. 228) for Mental Health, prohibit information disclosed from records protected by these laws from being redisclosed, even to the client, without the specific written consent of the client or as otherwise permitted by such law and/or regulations. A general authorization for the Release of Medical or Other Information is NOT sufficient for these purposes. Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse, and/or gambling client. Civil and Criminal Penalties may attach for unauthorized disclosure of alcohol/drug abuse, mental health, or HIV/AIDS information.
* Document Name:
Please describe this release using the following format: Consent for Release - John Smith - Father
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