Name:                                                                                                                                          Date of Birth:

 

 

Admit date:                                                                                                                                Social security number:

 

 

Your medical records contain information furnished by you, the patient, the patient’s family & the treating physician. It includes all test results like HIV, RPR & other communicable diseases. Federal regulation 42 CFR,

Part 2 prohibits further disclosure of information related to alcohol & or drug usage without the consent of the person to whom the information relates.

 

Following due consideration to the above, I, the undersigned, do hereby authorize Grace Point Behavioral to release or receive the information concerning my hospitalization at the named facility here:

 

 

Information to be released:  (Circle one)                                                                       Dates of treatment:

 

History and Physical:                                                                                                             Discharge summary:

 

Psychiatric evaluation:                                                                                                           Other :

 

This information is released for the purpose of :

 

Continuity of care                                                                                  Reimbursement for treatment

 

Legal:                                                                                                            Other:

 

This consent is voluntary & I understand the specific type of information being requested, & the benefits & disadvantages of releasing said information. I agree to indemnify & hold harmless, Grace Point Behavioral & or its medical staff from all liability that may arise from the release of the information herein requested. All information released may be subject to re - disclosure by the recipient.

 

This release is valid for a period not to exceed 1 (one) year from the date of signing, unless expressly revoked. I further agree that this information may be released verbally, by mail, fax, email or fax machine. This consent is subject to revocation at anytime except to the extent that the program making the disclosure has already taken action whilst relying on it.

 

 

If not previously revoked, this consent will terminate upon this date:

 

 

Expiration:

 

Patient signature:                                                                   Date:                        

 

 

Parent or Guardian :                                                                 Witness attesting to the validity of the above signature:

 

 

Date: