• New London, Newport, Claremont & the Upper Valley

Authorization to Disclose Health Information

I, born on this date DOB
authorize Counseling Associates of NewLondon, Newport, Claremont & UpperValley
  • Release
  • Receive
  • Exchange
  • Protected health information about me to:
Name
Address


Information as described below:
Category of Protected Health Information: I authorize the disclosure of information from the following categories of protected health information (check those that are applicable):
  • Both (MH/SUD)
  • Mental Health
  • Substance Use Disorder
Type of Information/Record:

Check Yes or No if you request the Entire Record includes, but not limited to, assessment, treatment plans, progress notesmedication, attendance, test results, behavioral support plans, discharge reports, etc.

  • Yes
  • No

If you checked No for the "Entire Record", please check Yes or No the information/record type you wish disclosed

  • Yes
  • No
  • Attendance
  • Yes
  • No
  • Assessments/Evaluations including diagnosis, treatment recommendations
  • Yes
  • No
  • Treatment Plan/Individual Plan of Care
  • Yes
  • No
  • Progress Notes
  • Yes
  • No
  • Medications Prescribed
  • Yes
  • No
  • Agency Discharege Summar/Plan
  • Yes
  • No
  • Behavioral Support Plans
  • Yes
  • No
  • Test Results (includes lab results and urine toxicology results)
  • Yes
  • No
  • HIV/AIDS
  • Yes
  • No
  • Other (must specify)
The purpose of the disclosure
If Other Specify

Date range of information to be disclosed
If Other Specify

Date or event upon which this authorization will expire
If Other Specify

I understand if I do not note a date or even, then this authorization will expire one year from the date signed below.
(If none is indicted the means of this disclosure may be written, verbal or electronic.)
  • I understand that my substance use disorder treatment records are protected under federalregulations, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unlessotherwise allowed by the regulations or required by law.
  • I understand that the Health Insurance Portability and Accountability Act of 1996 ("HIPPA"),45 C.F.R. Parts 160 & 164, protect all of my healthcare records and may only be disclosed aspermitted by the regulations or with my authorization.
  • For disclosures of information made to organizations outside of the State of New Hampshire,health information used or disclosed pursuant to the authorization may be subject toredisclosure by the recipient and no longer protected by the Privacy Standard of the HealthInsurance Portability and Accountability Act of 1996.
  • I understand that confidentiality of such records is also protected by State law.
  • I understand that generally Counseling Associates may not condition my treatment onwhether I sign an authorization form, but that in certain limited circumstances I may bedenied participation in the services if I do not sign an authorization form.
  • I understand that I may be denied services if I refuse to consent to a disclosure for purposes oftreatment payment or healthcare operations.
  • I also understand I will not be denied services if I refuse to authorize a disclosure for otherpurposes.
  • I understand that I may request restrictions on the use or disclosure of information for thepurposes of treatment, payment and healthcare operations that Counseling Associates may ormay not agree to the requested restrictions.
  • I understand I may revoke this authorization at any time except to the extent that the practiceor other agency making the disclosure has already acted in reliance on it. In generalrevocation should be submitted in writing and sent to the practice at our address.
I have read all of the above information and I understand its content and authorize the disclosure of confidential information identified above to the party listed above.
 
Name of Client (Please Print)

Signature of client or Parent/Guardian

Date
   
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