Joint Release Form


 

Authorization for Use & Disclosure of Protected Information

Client Name:           SSN:     

Insurance Info:

Provider:       Policy Holder:        Policy Number:      

 

I understand that I may refuse to sign this form and that services cannot be denied based on my
refusal to sign. This form implements the requirements for client consent to use and disclose
information protected by the federal health privacy law (45 C.F.R. parts 160, 164), the federal
drug and alcohol confidentiality law (42 C.F.R. part 2), HIV-AIDS (45 C.F.R. Parts 160 & 164)
and state confidentiality law governing mental health, developmental disabilities, and substance
abuse services (G.S. 122C).

Initials:      Date: 

I,      

hereby authorize:     

(Note: NOT your name, but rather the person or agency to share information with)

 To

Protected Health Information with: Grandis Evaluation Center PC               

The purpose of this disclosure is for: 

 

 

The protected information to be used/disclosed includes: 

Other (if applicable):   

REDISCLOSURE (See Notice of Privacy Act)
Once information is disclosed I understand that laws protecting health information may not apply
to the recipient. When the Grandis Evaluation Center, PC discloses information regarding
mental health, developmental disabilities and or substance abuse treatment we must inform the
recipient that redisclosure is prohibited except as permitted and/or required by law.

REVOCATION/EXPIRATION
I understand that, with certain exemptions, as described in the Notice of Privacy Act, I have the
right to revoke this authorization (in writing) at any time. If not revoked in writing this
authorization automatically expires one year from the below signed date.

Initials of Client or Legally Responsible Person:                                                                                                                                                                                                                                                                                             Relationship to Client (if applicable):   Date: 

Leave this empty:

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Signature Certificate
Document name: Joint Release Form
lock iconUnique Document ID: 054d858a845c52d2eff656afeacafb828c0aa21b
Timestamp Audit
March 28, 2018 11:14 pm ESTJoint Release Form Uploaded by Mike Grandis - info@gectesting.com IP 96.32.111.183