Counseling Associates of New London : Client Forms

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.

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 Entire Record - A Yes or No choice is Required 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

Authorization to Disclose Health Information