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Marshalltown Residential Facility Consent to Release Information-

Substance Abuse Treatment Unit of Central Iowa
9 North 4th Ave
P.O. Box 1453
Phone 641-752-5421
Fax 641-752-7211
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
I authorize SATUCI and all its subsidiaries to disclose to:
I authorize SATUCI and all its subsidiaries to disclose to    Name and address of organization
Treatment Coordinator:    Not needed if medical, behavioral health, or substance abuse provider
Residential Manager:
To disclose the following information    With DHS- usually select- Attendance, Discharge summary and plan, Drug test results, Progress in treatment, Diagnosis, and Evaluation Summary
Admission data   Attendance   Medication  
Assessment information   Patient demographic information   Treatment plan  
Discharge summary and plan   Progress notes   Treatment review  
Intake information   Drug test results   Progress in treatment  
Diagnosis   Evaluation summary   Financial balance  
Other     
* Purpose of disclosure:
I understand that my health records are protected under federal regulations (42 CFR, Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 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 at any time except to the extent that action has been taken in reliance on it, and that in any event this consent EXPIRES 365 DAYS AFTER MY DISCHARGE.  I understand that generally SATUCI may not condition my treatment 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.   I may review information released or ask questions by contacting the Compliance Officer at SATUCI. You may report violations to 42 CFR to the U. S. Attorney for the judicial district in which the violation occurred.  


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.
* Copies of all releases/consent forms were offered to, and were
Accepts Copy   Refused Copy    
I give specific Authorization to release the following information this is protected by state of federal law
Substance Dependence (drugs or alcohol)   Genetics   HIV/AIDS Related information  
Mental Health Treatment/Diagnosis/Test Results     
Client Touch Signature( you may use the mouse to sign if your don't have a touch screen)
Signer Type: NextStep User
  Client (Please click "Sign with Topaz" 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 Topaz" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Topaz
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