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Privacy Policy
AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
I, the Undersigned, authorize: HIGHTOWER BEHAVIORAL HEALTH to allow the use and sharing of protected health information about - Client name
Date of Birth
This authorization will remain in effect until: (specify date)
The Mental Health Information Authorized for Release includes : (check all that apply)
Copies of Records
Discharge Summaries
School Visitation:
Person/Organization authorized to receive your information
School
Address
Phone #
Fax #
Purpose of Release
I understand that I can revoke or cancel this authorization at any time by sending a letter to the Privacy Officer of the organization 1 is ted above and which is to supply this information. If I do this it will prevent any releases after the date it is received but cannot change the fact that some information may have been sent or shared before that date. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the professional or facility listed at number 4 above, nor will it affect my eligibility! it for benefits. I understand that I may inspect and I have a copy of the health information described in this authorization. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above way be re-disclosed and no longer protected by those regulations. I understand that II is professional or facility will receive compensation for the use or disclosure of my health information, The arrangement has been explained to me and I understand and accept it. I affirm that everything in this form that was not clear to me has been explained and I believe I wow understand all of it. I acknowledge that the information to be used or disclosed as a result of this Authorization may include records that are protected by other federal and/or state laws applicable to substance abuse. 1 specifically authorize the release of confidential information relating to drug and/or alcohol abuse, psychiatric, HIV results and or AIDS information. The recipient of drug and/or alcohol abuse information disclosed as a result of this Authorization will need my further written authorization to re-disclose this information. 42 C FR 2.32 restricts any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.
Client/Parent/Guardian Signature
❌
Date
NEXT: CLIENT ACKNOWLEDGEMENT OF INFORMATION
HIGHTOWER BEHAVIORAL HEALTh
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