Joint Release Form
Client Name: SSN:
Provider: Policy Holder: Policy Number:
I understand that I may refuse to sign this form and that services cannot be denied based on myrefusal to sign. This form implements the requirements for client consent to use and discloseinformation protected by the federal health privacy law (45 C.F.R. parts 160, 164), the federaldrug 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 substanceabuse services (G.S. 122C).
(Note: NOT your name, but rather the person or agency to share information with)
To Disclose and/or Share
Protected Health Information with: Grandis Evaluation Center PC
The purpose of this disclosure is for: AssessmentOutpatient Therapy
Other (if applicable):
REDISCLOSURE (See Notice of Privacy Act)Once information is disclosed I understand that laws protecting health information may not applyto the recipient. When the Grandis Evaluation Center, PC discloses information regardingmental health, developmental disabilities and or substance abuse treatment we must inform therecipient that redisclosure is prohibited except as permitted and/or required by law.
REVOCATION/EXPIRATIONI understand that, with certain exemptions, as described in the Notice of Privacy Act, I have theright to revoke this authorization (in writing) at any time. If not revoked in writing thisauthorization 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:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Joint Release Form
Agree & Sign