The undersigned authorizes the provider and primary physician to release/obtain the following medical records and information concerning the client. The purpose of such release is to allow for coordination of care, which enhances quality, and reduces the risk of duplication of tests and medication interactions. Refusal to provide consent could impair effective coordination of care.
- Current medication/treatment plans
- Substance dependence assessments
- Assessment/evaluation report
- Discharge reports/summaries
- Laboratory/diagnostic test results
- Medical History
- Other
I understand that this authorization includes written, electronic, verbal and/or telephone communication and will remain in effect for the duration of my treatment. I may revoke this authorization at any time by written request. A photocopy of this release will be accepted as comparable to the original.
I further understand that federal law prohibits disclosure of matters concerning regulated substances (such as illicit drugs and/or alcohol) without explicit written consent regarding such matters. HIV-related information and drug and/or alcohol information will be released under this consent unless indicated here:
