AUTHORIZATION FOR RELEASE OF MEDICAL RECORD …



495300000AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATIONI authorize: and: to exchange information for the purpose of [ ] continued treatment, [ ] reimbursement for treatment, [ ]evidence of care, [ ] otherregarding: (Print patient's name)(Birthdate)The information to be released/exchanged includes: [ ] medical information only[ ] medical records only[ ] medical information and records[ ] limited release (requires OM approval)I understand that my records are protected under Federal (42 CFR, Part 2) and State Confidentiality regulations.I understand that I may withdraw this consent at any time in writing except to the extent that a custodian of my medical records relied on it.I understand that this authorization shall remain in effect for one hundred twenty (120) days after I sign and date this form, unless otherwise specified.I understand that a file copy is equivalent to the original.I understand that I have the right to inspect and copy the information I authorized to be disclosed.I consent to the release of records containing mental health/ psychiatric information to be included in this authorization.I consent to the release of records containing substance abuse/dependency information, if applicable, to be included in this authorization.I consent to the release of records containing testing for or infection with Human Immunodeficiency Virus (HIV), if applicable, to be included in this authorization.I consent to the release of records containing Genetic testing results, if applicable, to be included in this authorization.I understand that my refusal to consent to the release of the information above will prevent the disclosure of the information.I further acknowledge that the information to be released was fully explained to me and this consent is given of my own free will.I understand that I have the right to revoke this authorization in a written and dated statement.I understand that my physician may not condition treatment on whether I sign this authorization.I understand that the information being released that does not fall under (43 CFR, Part 2 regarding drug and alcohol abuse) has the potential to be re-disclosed by the recipient.I understand that a copy of this Authorization for Release of Medical Record Information has been made available to me.Executed this day of in year Expiration date: WitnessPatientParent or Authorized RepresentativeRelationshipNOTE TO RECIPENT OF DRUG AND ALCOHOL ABUSE INFORMATIONThis information has been disclosed to you from records protected by Federal confidentiality rules (43 CFR, Part 2). The Federal rules prohibit you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse victim.MEDICAL RECORDS REQUESTDate:Patient Name:Patient's Doctor/ Therapist:[]Hold release in patient chart to exchange information with: (i.e. doctor, therapist, work, school, attorney, etc.)Name Address Fax Phone []Please send medical records to:Name Address Fax Phone []Please obtain medical records from:Name Address Fax Phone PLEASE FORWARD COMPLETED FORMS TO ADVENT BEHAVIORAL CARE, 255 SPENCER ROAD, ST. PETERS, MO 63376. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT OUR OFFICE AT 636.939.2550 OPTION 6 ................
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