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Release of Information

(Please read this carefully and sign at the bottom)

We cannot discuss your program, progress or health information with anyone---not even your spouse or loved ones---without written permission. 

Submit the form below to tell us with whom and what we can share.  Think ahead to your treatment and submit as many times as you need.  For instance, Spouse, Loved One, Doctors, Attorney, Parole Officer or person paying for your treatment should each be submitted separately. 

One form per one person or organization.

* Your Name

* Last 4 digits of your SS#

* Who may we share your health information with: (Person or Organization)

 * Select the types of information that we may share:
General summary of my progress (program, attendance and abstinence)

Financial and Insurance Information

Detailed Clinical Records

Other Describe

I have read and understand the full terms as follows:

(1) I allow my insurance company or group health plan to re-disclose my information as necessary for payment, for their internal business purposes, or if my insurance company or group health plan is required to make the disclosure by law.

(2) I understand that my records are protected under Federal regulations governing confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part 2) and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that this disclosure will reveal my presence as a patient at this treatment facility or that I am receiving this type of treatment.

(3) I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it by contacting Recovery Help in writing. This consent will last for 180 days after I leave treatment, or, in the case of payment, when my account has been settled, unless the program and/or physician specified above is notified by me that I am revoking my consent.

* Signature