Authorization for Use and Disclosure

Release of Information

Authorization for Use and Disclosure
This Release of Information (ROI) applies to all Health Solutions programs and locations, including behavioral health, substance use disorder services, and primary care services.
Client Information
Legal Name *

First NameLast Name
Date of Birth *

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize Health Solutions to use and disclose my protected health information, including substance use disorder (SUD) records protected under 42 CFR Part 2, as described in this authorization. This authorization permits disclosure to individual(s), organization(s), or class of recipients listed below and, unless otherwise limited by me, permits disclosure to HIPAA-covered entities and business associates for purposes of treatment, payment, and health care operations (TPO)

This release authorizes two-way communication between Health Solutions West and the listed party.
To be released to/from:
Name

First NameLast Name
Agency Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Check all types of information to be disclosed:*

Continuity/Transition of Care PacketPhysician OrdersPsychiatric EvaluationsLab/Diagnostic ReportsHistory and PhysicalProgress NotesDischarge SummaryHIV/AIDS Results and TreatmentOther
Substance Use Counseling Notes

I agree to the use and disclosure of my substance use disorder (SUD) counseling notes. A Part 2 program may not require me to check this box as a condition of treatment, payment, enrollment in a health plan, or eligibility for benefits. SUD Counseling notes may contain detailed information, including but not limited to conversational content, analysis, information about the client's emotional/cognitive state, and specific risks.
The information will be used for the following purposes:*

Additional Evaluation or TreatmentClient RequestContinuity of CareLegal ProceedingsMulti-Agency CoordinationObtaining Client Resources or BenefitsProfessional ConsultationReports to Court or Other AgenciesRepresentative/GuardianRequestService planningTreatment, Payment or Healthcare OperationsOther
This authorization will expire two years from signature if not revoked.
This authorization is intended to allow Health Solutions to release information, both written and verbal, for the specific purpose and life of the release and in the best interest of the patient. This release of information demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR 160 and 164, 42 CFR Part 2 and all state and federal regulations and interpretive guidelines promulgated there under. You may not be compelled to sign this authorization, and you have the right to revoke this authorization by written request at any time. Exceptions to this can be reviewed in the Notice of Privacy Practices. The revocation will not apply to information that has already been released in response to this authorization. Once the above information is disclosed, it may be subject to re-disclosure by the recipient and may no longer be protected by federal regulations. You have the right to inspect and receive a copy of the information that is to be disclosed. Choosing not to sign this authorization will prevent the above indicated purpose from being achieved. Treatment or payment for services is not conditioned on signing this authorization. A fee may be associated with the copying of your information in the processing of this request.
I understand the terms of this consent, and my right to obtain information on the disclosure of my record. *

Clear
Date

MonthDayYear
Date
If signed by a representative, please state the relationship/authority to consent
Revocation
By signing, I withdraw consent for release of my health information to the party or parties named above:

Clear
Should be Empty:

Release of Information

Client Information

To be released to/from:

Revocation