Florida Department Of Corrections Consent And Authorization For Use And Disclosure Inspection And Release Of Confidential Information

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FLORIDA DEPARTMENT OF CORRECTIONS
CONSENT AND AUTHORIZATION FOR USE AND DISCLOSURE INSPECTION AND RELEASE
OF CONFIDENTIAL INFORMATION
I,
authorize
(Name, organization or general designation of program making disclosure)
to disclose to
(Name of person(s) or organization(s) and address to which disclosure is to be made)
Purpose of disclosure authorized herein:
The undersigned hereby authorizes the inspection and release of copies of my medical records indicated below by the above-named health
care facility/medical record custodian only to the above-named entity(ies) or persons or their agents. Indicate all of the records authorized
to be inspected/released by initialing in the appropriate box(es) below:
INITIAL BELOW
FOR RELEASE OF
INFORMATION
A.
Release of all medical records except: any information relating to HIV testing, AIDS and AIDS-related
syndromes; psychiatric and psychological information; or alcohol and substance abuse treatment information
related to my condition, care, and confinement (initial box).
B.
Release of any records regarding HIV testing, AIDS and AIDS-related syndromes relating to my condition,
care, and confinement (initial box).
C.
Release of any records of psychiatric and psychological information (mental health records) other than
psychotherapy notes relating to my conditions, care, and confinement (initial box).
D. Release of all dental records relating to my condition, care and confinement (initial box).
E.
Release of any records regarding alcohol and substance abuse treatment relating to my condition, care, and
confinement.
I understand that my records are protected under the federal regulations governing
Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Subchapter A, Part 2, and cannot be
disclosed without my written consent unless otherwise provided for in the regulations. As to release of
alcohol/substance abuse treatment records, please state the specific information to be released as provided by
42 C.F.R., Subchapter A, Part 2 (initial box):
Name of information -- dates of treatment/programs, etc., if possible
NOTE: IF PSYCHOTHERAPY OR SUBSTANCE ABUSE PROGRESS NOTES ARE THE SUBJECT
OF THE RELEASE, OTHER RECORDS CANNOT BE THE SUBJECT OF THE SAME
AUTHORIZATION.
RELEASE OF PSYCHOTHERAPY OR SUBSTANCE ABUSE PROGRESS
NOTES IN ADDITION TO THE RECORDS SPECIFIED ABOVE WILL REQUIRE A SEPARATE
AUTHORIZATION (SEE BELOW).
I understand that I may refuse to sign this authorization and my refusal to sign will not affect my access to health care treatment,
eligibility for benefits or enrollment, or payment for or coverage of services. I also understand that once my protected health
information is disclosed pursuant to this authorization, it may be used and/or redisclosed by the recipient unless the recipient is
covered by law which prohibits or limits its use and/or disclosure.
I understand that I may revoke this consent and authorization at any time, provided the revocation is in writing, except to the extent that
action has been taken in reliance on it, and that in any event, this consent and authorization shall be effective for 90 days unless I specify a
different expiration as follows:
(Specification of the date, event, or condition upon which this consent expires if less than six months or greater than 90 days)
In furtherance of this authorization, I (we) do hereby waive all provisions of law and privileges relating to the disclosures hereby
authorized. I acknowledge the extent of my authorization of release as to the records and information denoted in paragraphs A, B, C, D
and E by initialing the appropriate box(es) above.
_________
__________________________________________________________
SIGNATURE OF PATIENT
(Guardian or Statutorily Authorized Representative, when required)
Date
AUTHORIZATION FOR RELEASE OF PSYCHOTHERAPHY OR SUBSTANCE ABUSE PROGRESS NOTES
I,
authorize
(Name, organization or general designation of program making disclosure)
to disclose to
(Name of person(s) or organization(s) and address to which disclosure is to be made)
DC4-711B (English) (Revised 11/27/07)
Incorporated by Reference in Rule 33-601.901, F.A.C.

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