Medical Records Request

1. I understand that I have the right to revoke this authorization at any time, by submitting written notice to the Privacy Officer. I understand that the revocation will not apply to information that has already been released in response to this authorization. 2. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. 3. I understand that authorizing the use or disclosure of the information identified above is voluntary I need not sign this form to ensure treatment. 4. I understand that I will receive a copy of the signed Authorization. 5. I understand that my alcohol/drug treatment records are protected under the Federal regulation governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42, C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R, Parts 160 and 164 and cannot be disclosed without my written consent unless otherwise provided for the regulations. Two witnesses to the consumer’s signature should be secured if the consumer signs with a mark or if consent is given by telephone. When Authorization is given by telephone, the consumer’s actual signature should be obtained at the earliest opportunity.

Requests made by a parent or guardian for individuals age 16 and over require both the individual’s and parent/guardian signature.

Upon submission, you will receive a confirmation email. Our Quality Assurance Specialist will contact you within 5–10 business days to verify your request and confirm processing details.