Type of ServicesRecovery CoachingClinical ServicesSober Living

Name

Date Of Birth

Pronouns

Email

Phone Number

Client Address

Organization

Email

Contact Number

Title

Name

Phone

Email

Relationship

Consents and Documentation Date:

(Person/Company)

Phone Number

Email

Client Address

Other:

I may revoke this authorization at any time, except for information which has already been released in accordance
with the authorization prior to my revocation.

By checking "Yes" below, I authorize information to be exchanged freely by both parties identified in this
release
YesNo

Expiration Date (one year from todays date)

AUTHORIZATION: I hereby give permission to disclose my individually identifiable health information as listed
above. I understand that once this information is disclosed, it may no longer be protected. I understand that this
authorization is voluntary, that further treatment cannot be condition upon my signing this authorization. I
acknowledge that incomplete forms cannot be processed.

REVOCATION: I understand that I must provide staff with verbal notice as well as a written signature and date on
my client chart if I choose to revoke this authorization before the date/event of expiration, and that the written
revocation must be signed and dated with a date that is later than the date on this authorization.

I have been told that in order to protect the limited confidentiality of records, my agreement to obtain or release is necessary, and this permission is limited for the purposes and to the person listed above and will be effective during
the date listed below. I also understand that this consent is revocable except to the extent which records have been
sent.

I understand that my alcohol and/or drug treatment records are protected under the federal regulate governing
Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 and the Health Insurance Portability
and Accountability Act of 1996 ("HIPAA"), 45 C.R.R. Pts. 160 & 164. I also understand that I may revoke this
consent at any time except to the extent that action has been taken in reliance on it, and that any event this consent
expires automatically as follows:

I will be given a copy of this authorization for my own personal records.

This consent shall be in effect for two years from the date indicated below.