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 >ROI-Orchard Medical

 

Release of Information to/from Orchard Medical

(This is a binding contract and required before we can provide treatment services. Please read carefully and sign at the bottom)
 


I hereby authorize Recovery Help to discuss with or disclose to and from my protected health information with Orchard Medical.

Protect Health Information

This consent allows the disclosure of all my clinical and treatment records, without limitation, including diagnosis, assessment, treatment, progress notes, discharge information.

Billing Purposes

I also allow Orchard Medical or my insurance company or group health plan to re-disclose my information to my insurance company, group health plan or 3rd party payer as necessary for payment, for their internal business purposes, or if Orchard Medical, my insurance company or group health plan is required to make the disclosure by law.

Applicable Laws & Regulations

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.

Right to Revoke This Consent

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.

Electronic Signature

You further understand that when you interact online with Recovery Help systems and websites that your typed name becomes your electronic signature in place of your written signatures. You also understand that faxed or scanned copies of documents with my typed signature are to be considered original signatures.

Acknowledgement

By signing below, I acknowledge that I have read, understand and agree to the terms and conditions stated above.

Signature (Type Your Name)..