Release of Information

I, Client, or my personal representative (parent or legal guardian) hereby authorize the Behavioral Health Wellness Clinic (BHWC) to use and disclose health information and substance use disorder treatment information with my treating health care providers. The information may be used/disclosed for the treatment, payment and health care operations and other permissible purposes under applicable law and regulations. The health providers rendering treatment may also use these information as necessary for its own treatment, payment or health care operations activities such as care coordination.

Client First Name(Required)

Middle Name

Client Last Name(Required)

Client Date of birth(Required)

Client Phone(Required)

Email

Client Address

Street Address Address Line 2 City State ZIP Code

DISCLOSURES TO RECIPIENTS

I, Client, or my personal representative (parent or legal guardian) hereby authorize Behavioral Health Wellness Clinic (BHWC) to release health information and substance use disorder treatment information to the following (person or entity):

Person or entity to release health information to:(Required)

Who would you like your ANTHC Behavioral Health Wellness Clinic health information sent? The name of the person or the organization you would like us to send your records to.

Recipient or Entity Phone(Required)

Recipient or Entity Mailing Address

Street Address Address Line 2 City State

Untitled

Zip Code

Recipient or Entity Fax

Recipient or Entity Email

If you are having any difficulties with this form, please call us at 1 (833) 642-BHWC (2492) or (907) 729-BHWC (2492) for assistance.

TYPE OF INFORMATION TO BE RELEASED / REQUESTED

I authorize disclosure / discussion of the following (check all appropriate boxes):(Required)

All my BHWC behavioral health record information and substance use disorder information

Only BHWC behavioral health information

Only BHWC substance use disorder information

Substance Use Assessments (Psychiatric Diagnostic Evaluation)

Behavioral Health Assessments and Individual Counseling Progress Notes

Letter of Confirmation of Care

Case Management Notes

Other (Specify)

Other(Required)

If you are having any difficulties with this form, please call us at 1 (833) 642-BHWC (2492) or (907) 729-BHWC (2492) for assistance.

Purpose of Disclosure

Why are you requesting this release of information?(Required)

Please be as specific as possible and the purpose behind requesting this release of information.

LENGTH OF AUTHORIZATION

Unless revoked, this authorization is limited to the following time period, which must be no longer than reasonably necessary to serve the purpose of the disclosure:

Beginning date of authorization(Required)

End date of authorization(Required)

If you are having any difficulties with this form, please call us at 1 (833) 642-BHWC (2492) or (907) 729-BHWC (2492) for assistance.

APPLICABLE LAW

By signing this authorization form, I understand and agree that: My protected health information and substance use disorder treatment information is protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and federal regulations governing the confidentiality of substance use disorder patient records, 42 CFR Part 2. Recipients of my information pursuant to this authorization may not further disclose my substance use disorder information without my consent, unless permitted under HIPAA; 42 USC § 290dd-242; and 42 CFR Part 2. Recipients will be notified of this obligation in the Prohibition on Re-Disclosure which must accompany all disclosures of my substance use disorder information. 42 CFR § 2.32. I may revoke this authorization in writing at any time by notifying BHWC, except to the extent that BHWC has already used or disclosed information in reliance on my authorization. I will not be denied services if I consent to disclosure, unless disclosure is necessary for BHWC’s proper treatment of me, obtaining payment for my services, or its health care operations. I have been given time to read, understand, and ask questions about this form.

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SIGNATURE

Signed Date

Patient name(Required)

Please type patient name here.