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Authorization for Release of Protected Health Information for School Districts

Release of Protected Health Information for School Districts

Authorize:

PsyCare Clinic

520 Youngstown-Poland Road

Struthers, Ohio 44471

Phone:  330.318.3078

Fax:  234.855.1072

To:
The following information for the years  present-discharge
The following information for the years: Present--Discharge *
The purpose of the disclosure is to: provide continuity of care

I understand that:

  1. This authorization extends to all or any part of the records/information designated above which may include diagnosis and/or treatment for physical and mental illness, alcohol/drug abuse, HIV/AIDS, and may include health information from sources other than PsyCare, Inc.
  2. I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, (January 1, 2020) and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.
  3. The information disclosed is protected by law and may not be re-disclosed without my written authorization or as otherwise authorized by law; however, if the person or entity who receives the information is not a health care provider or health plan covered by the federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations.
  4. I may revoke this authorization at any time by providing written notice to the disclosing agency/individual named above as described in the Notice of Privacy Practices, except:

A.In the case where action has already been taken; or

B.This authorization is obtained as a condition for obtaining insurance reimbursement.

  1. The person or entity making the disclosure cannot control the recipient’s use of the information.
  2. I may review the information to be released by contacting the releasing agency/individual named above.
  3. This authorization is voluntary and I may refuse to sign this authorization. Unless allowed by law, my refusal to sign this authorization will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits.
  4. If not previously revoked, this authorization will expire upon written revocation or discharge (date, event or condition). If no date, event, or condition is specified, then this consent will automatically expire 180 days from the date of signing.
I certify that I am (Check the appropriate line): *