Authorization To Release Information (Page 2 of 2) in pdf

SECTION II. SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED BY STATE OR

FEDERAL LAW CONCERNING MENTAL HEALTH, SUBSTANCE ABUSE TREATMENT OR AIDS-RELATED

INFORMATION

I acknowledge that information to be released may include material that is protected by Federal and/or State law

applicable to substance abuse, mental health, and/or AIDS-related information. I SPECIFICALLY AUTHORIZE the

release of confidential information relating to: [Place "YES" or "NO" in ALL applicable boxes:]

___ Substance Abuse (Drug or Alcohol) information from all health care providers and facilities and any

other person or entity in possession of records concerning me.

___ Mental Health information from all health care providers and facilities and any other person or

entity in possession of records concerning me.

___ HIV or AIDS-related information, Diagnosis, and test results from all health care providers and

facilities and any other person or entity in possession of records concerning me.

Furthermore, I SPECIFICALLY AUTHORIZE disclosure and re-disclosure of this confidential information to all of the

persons referred to in the REDISCLOSURE Section I.

In order for the above information to be released you must sign here AND at the end of Section I

Signature of Claimant or Legal Representative

Date

Street Address

City/State/ Zip Code

Printed Name and Relationship of Claimant's Legal Representative

Federal and/or State law specifically require that any disclosure or REDISCLOSURE of substance abuse, alcohol or

drug, mental health, or AIDS-related information must be accompanied by the following written statement:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR

Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further

disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise

permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT

sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or

prosecute any alcohol or drug abuse patient.

See also Chapter 228 of the Iowa Code and Section 141.23(3) of the Iowa Code and other applicable laws.

14-0043 (11-04) This form my be used in connection with claims under the jurisdiction of the Iowa Workers’

Compensation Commissioner.

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