Medical Records Release

Consent

I hereby authorize the use or disclosure of my protected health information as specified below. I understand that this authorization is voluntary and that I may refuse to sign it and it does not prevent me from receiving services. I understand that this information is needed:

Check all that apply

to ensure continuity of careto monitor my response to treatmentto assist in appropriate treatment planningother

if other, please specify:

Provider/Destination

Select One *

I authorize the Arthur Center/Options Unlimited/Hope Center to release information to:I authorize the Arthur Center/Options Unlimited/Hope Center to receive information from:

Name of Program/Person and Title

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone

Fax

Release Details

The following information may be released or obtained:

AssessmentDischarge SummaryIntakes/EvaluationsTreatment Plan and/or ReviewsPsychological TestingHistory & PhysicalProgress NotesLab ReportsInsurance Information/FinancialAlcohol and Drug Abuse TreatmentOther

If Other, please specify:

Date(s)

For dates of service:

From Date

To Date

Release Format

I request the information to be released be in the following format: *

PaperFaxElectronic

If electronic, specify format:

Release Request Confirmation

I release all parties stated here within from any legal liability resulting from the release of this information, with the understanding that all parties involved will exercise sufficient safeguards while using this information. I hereby release Arthur Center/Options Unlimited/Hope Center and all employee from any and all liability, claims or causes of action for providing you medical information requested regarding treatment, hospitalization, outpatient care including psychological, psychiatric, drug abuse, alcoholism, sickle cell anemia, acquired immunodeficiency (AIDS), or test for infection with human immunodeficiency virus (HIV).

Redisclosure I understand that information used or disclosed as a result of this release may no longer be protected by federal law, and could be redisclosed by the receiving party. I have the right to inspect or request a copy of information that has been disclosed. If Arthur Center/Options Unlimited/Hope Center initiated the release of informatin, I have the right to a copy of the release. If additional questions, I understand that I can contact the Privacy Officer at any time by calling (573) 582-1234. A photocopy or faxed copy of this authorization shall be fully effective as valid for all purposes as the original hereof.

Expiration: I understand that unless I revoke the authorization earlier, this authorization will automatically expire one (1) year from the date this Authorization was signed.

Electronic Signature Notice

By typing my full name below, I am signing this request electronically. I agree my electronic signature is the legal equivalent of my manual signature on this request.

Client's Full Name *

Date *