Authorization Form To Release Patient Medical Information (Page 2 of 2) in pdf

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*DRUG AND ALCOHOL ABUSE TREATMENT INFORMATION:

Federal regulations (42CFR part 2) prohibit any further disclosure of this information except with

specific written consent of the person to whom the information pertains or the parent or legal

guardian of a minor child to whom it pertains, unless otherwise permitted by federal law. A

general authorization for the release of information is NOT sufficient for this purpose.

This consent is subject to revocation at any time except to the extent that the program which is to

make the disclosure has already taken action in reliance on it.

The federal rules restrict any use of information to criminally investigate or prosecute any alcohol

or drug abuse patient. Federal regulations state that any person who violates any provision of the

law shall be fined not more than $500 in the case of a first offense and not more than $5000 in the

case of each subsequent offense. (see 42 U.S.C., 290dd-3 and 42 U.S.C., 290ee-3.)

MENTAL ILLNESS INFORMATION:

State law prohibits any further disclosure of mental illness information without specific written

consent of the person to whom the information pertains, or the parent or legal guardian of a minor

child to whom it pertains, unless otherwise permitted by State Law. A general authorization to

release information is NOT sufficient for this purpose. (See RCW 71.05.390 through RCW

71.05.410.)

***SEXUALLY TRANSMITTED DISEASE INFORMATION: (Includes HIV

AIDS)

State law prohibits any further disclosure of this information without specific written consent of

the person to whom the information pertains, or the parent or legal guardian of a minor child to

whom it pertains, unless otherwise permitted by State Law. A general authorization to release

information is NOT sufficient for this purpose. Any Violation of the law is a gross misdemeanor,

and the law creates civil remedies for any violation which includes a $1000 fine for negligent

violation, a $2000 fine for an intentional or reckless violation or actual damages, whichever is

greater, and attorney fees. (See RCW 70.24 and WAC 248-100.)

CONSENT OF MINOR (age 14 and above for Drug and Alcohol, and Sexually Transmitted

11W);

Disease information (including AIDS /

13 and above for Mental Health Information).

A minor patient’s signature is required in order to release information concerning care for: (1)

pregnancy termination and sexually transmitted diseases; (2) alcoholism or drug abuse; and (3)

mental health conditions.

Authorization Form To Release Patient Medical Information Page 2