CONSENT TO TREATING PROVIDER ENTITY RECIPIENT
42 CFR Part 2 and HIPAA
REMINDER: Information disclosed pursuant to patient consent must be accompanied by the notice prohibiting redisclosure.
A "treating provider relationship " exists when a patient receives, agrees to receive, or is legally required to receive diagnosis, evaluation, treatment, or consultation, for any condition, from an individual or entity who undertakes or agrees to undertake that diagnosis, evaluation, treatment, or consultation. An in-person encounter is not required for a treating provider relationship to exist.
This consent form is for use when a patient wishes to authorize the disclosure of their substance use disorder information to an individual or entity with which the patient has a treating provider relationship.
I, , authorize
Assessment and treatment records:
(describe how much and what kind ofinformation may be disclosed, including an explicit description ofwhat substance use disorder information mav he disclosed; as limited as possible)
to HOPE Counseling & Consulting Services, Inc., 326 N Spring St, Winston Salem, NC 27101 for purpose of treatment / counseling services at HOPE Counseling
I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and substance Use Disorder 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 by the regulations.
I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:
(describe date/event/condition upon which consent will expire; must be no longer than reasonably necessary to serve the purpose of this consent)
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 permitted 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: June 27, 2022
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent To Treating Provider Entity Recipient
Agree & Sign