Authorization/denial To Obtain Or Release Information And Records Form Page 2
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2I understand that this authorization is subject to revocation at any time, with written notice by the resident or other
responsible party. The consent will last no longer than three months after services end.
Signature of Resident (Parent/Guardian if resident is minor)
Date
I do NOT authorize _____________________________ (Name of program) to release information to or obtain
information from: ___________________________________________________________________________________
(Name of agency/school/physician)
Signature of Resident (Parent/Guardian if resident is minor)
Date
PROTECTED INFORMATION
Your signature on the above portion of this sheet does not pertain to the categories listed below. Information in
these protected categories will not be released from your record without your signature on this page or a court
order. The authorization to release information pertaining to these protected categories is only valid for (check
one):
____ 30 days
____ 60 days
____ 90 days
____ 90 days after termination
____ Other: _______________________________________________
INITIAL ONLY THE CATEGORIES OR INFORMATION YOU WISH ________________________ (Name of
program) TO RELEASE:
____ Alcohol Abuse
____ AIDS
____Domestic Violence
____Mental Health
____ Drug Abuse
____ HIV Testing
____ Sexually Transmitted Disease
____ Hepatitis B Testing/Treatment
____ Hepatitis C Testing/Treatment
____ Other: _______________________
I understand that I have the right to inspect and copy the information to be disclosed, and that I may withdraw this
Authorization at any time except to the extent that action has been taken in reliance upon it. I understand that my
records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient
Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the
regulations.
Signature of Resident (or Parent/Guardian, if resident is a minor)
Date
Formatted By:
F
S
M
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T
AMILY
HELTER
ODEL
ECORD
EAM
Sponsored by the Department of Public Health, Bureau of Substance Abuse Services
Facilitated by The Quality Improvement Collaborative
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