Complete Behavioral Health


Authorization for Disclosure of Information

Disclosure of Information

After case/ Discharge Plan
Current Medication
Drug/ Alcohol Information / Evaluation
Financial resources & Eligibility
Individual Education Plan
Medical History
Progress Reports / Summary of treatment
Psychiatric History and Diagnosis
Psychiatric History and Diagnosis
Social History
Treatment/ Services Plan
Intelligence testing results
Psychotherapy notes
Determining eligibility for benefits or program
If requested record includes drug and alcohol information. I understand that my alcohol and drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drugs Abuse Patient Record, 42 C.F.R. part 2 and cannot without my written consent unless otherwise provided for in the regulations.
I understand this authorization may be revoked at any time, except to the extent that action has already been taken in reliance on this Authorization. I understand if I wish to revoke this authorization, I must do so in writing and present my written revocation to the Complete Behavioral Health.
Unless otherwise revoked, this Authorization will expire on the following date, event or condition . If I failed to specify an expiration date event or condition, this Authorization will expire six (6) months from the date below. I understand this authorization is voluntary. I can refuse to sign this Authorization. I need not sign this Authorization to receive treatment. I understand that I may inspect or copy the information to cause or disclose it, as provided in 45 CFR 164.524. I understand that any disclosure and the information may no longer be protected by federal confidentiality laws.
I have reviewed the HIPAA Notice of Privacy Practices information and agree. At my request, I am entitled to receive a copy of my rights to privacy.