Consent For The Release of Confidential Information
CONSENT FO THE RELEASE OF CONFIDENTIAL INFORMATION
I, , authorize HOPE Counseling & Consulting
Services to disclose to
the following information:
The purpose of the disclosure authorized in this consent is to:
I understand theat my alchohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alchohol 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. Pts. 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that the action has taken in reliance on it, and that in any event this consent expires automatically as follows:
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permtted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
I have been provided a copy of this form.
Date: December 6, 2022
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Document Name: Consent For The Release of Confidential Information
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