Authorization to Release/Obtain Information
Please read and sign the form below.
You can also download the form here: Authorization to Release/Obtain Information
Authorization to Release/Obtain Information
I hereby authorize House of Hope (see specific person/program below):
PROGRAM NAME: House of Hope Girls Program
ADDRESS: P O Box 21283, St Simons Island, GA 31522
TELEPHONE NUMBER: (912) 689-9840.
AND/OR
The protected health information authorized to be obtained/used or disclosed includes:
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Demographic information of client, medical records, psychological evaluations, medication records, treatment plans, admissions packet, health insurance information, placement into House of Hope’s Girls Residential Program, any transition/discharge plans.
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The protected health information is to be obtained/used or disclosed for the purpose of: Coordination and continuation of care of the referred client.
This authorization is in effect until:
I understand that the federal Privacy Rule (HIPAA) does not protect the privacy of information redisclosed, and, therefore, request that all information obtained from this person or agency be held strictly confidential and not be further released. I further understand that my eligibility for benefits, treatment or payment is not conditioned upon my provision of this authorization.
I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand I have the right to revoke this authorization, in writing, at any time.