Vdss Model Form - Alf - Authorization For Release Of Confidential Information Form printable pdf download

Vdss Model Form - Alf - Authorization For Release Of Confidential Information Form

VDSS MODEL FORM – ALF

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

(See 22 VAC 40-72-570)

REGARDING: _______________________________ DOB:________ SS#:______________

(

State full name of resident)

INFORMATION SOURCE (ALF name and address): _______________________________

______________________________________________________________________________

INFORMATION RECIPIENT: __________________________________________________

(Be as specific as possible regarding individual, title, agency and address)

______________________________________________________________________________________

LIST INFORMATION TO BE DISCLOSED: ______________________________________

______________________________________________________________________________

FOR THE PURPOSES OF: ______________________________________________________

This authorization is subject to revocation at any time, except when the information you authorized has

already been sent. If not previously revoked, this authorization will terminate in __30 days __60 days __90

days __180 days __365 days or upon the following date, event or condition: ___________________.

Revocation is not effective until delivered in writing to the person in possession of my records.

This authorization will automatically expire upon my discharge from the assisted living facility.

If the above named recipient has requested specific confidential health information, I understand

that my signature below provides written authorization for the release of that information. If my

information contains information about substance abuse and/or communicable disease status, I

authorize the ALF to release any pertinent substance abuse information and/or information relating

to my communicable disease status including HIV/AIDS status.

This authorization includes information placed in my record after the date of my signature and before the

expiration of my consent.

______________________________________________________

_______________________

Signature of ALF Resident

Effective Date of Consent

________________________________________________________

_______________________

Signature of Legal Guardian or Legal Representative

Effective Date of Consent

032-05-0019-03-eng (07/07)

Vdss Model Form - Alf - Authorization For Release Of Confidential Information Form