Pre-Adoption Services Authorization To Release Protected Information

Types of Release

One-time exchange of information

Ongoing exchange of information

Full Name of Person Signing Form

, do hereby authorize and request DePaul Community Resources to use or disclose Protected Health Information regarding the service user listed below.

Service User's First Name

Service User's Middle Name

Service User's Last Name

Service User's current information:

Date of Birth

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Social Security Number (optional)

Information may be released to the following Person(s), Agency or Health Care Entity

Yes

Person(s), Agency or Health Care Entity

Address

Street Address Address Line 2 City State ZIP Code

Information may be received from the following Person(s), Agency or Health Care Entity:

Yes

Name of Person(s), Agency, or Health Care Entity

Address

Street Address Address Line 2 City State ZIP Code

Please specify the Protected Health Information to be released by marking the following:

Other (Specify)

The Purpose of this disclosure is for:

Services Coordination / Provision of Services

At the request of the individual

Eligibility Determination

Other

Other (Specify)

Different agencies provide different services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information, including confidential health records, so it will be easier for them to work together more effectively to provide or coordinate services.

I can withdraw this Authorization at any time by notifying the DePaul in writing.

Withdrawal of this authorization does not affect any disclosure of Protected Health Information made prior to the receipt of written notice of revocation by the custodian of health records.

I have the right to see and receive a copy of the information described in this Authorization if I request it in writing.

My provision of services, payment, enrollment or eligibility for benefits will not be conditioned on signing this authorization.

There is a potential that information disclosed may be re-disclosed by the recipient and no longer protected by law (see note below re: 42 CFR Part 2).

A copy of this Authorization and a notation concerning the person or agencies to which disclosure was made shall be included with the original health records and I have a right to a copy of this Authorization.

My substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 CFR Part 2, and HIPAA, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it.

This authorization will expire on the following expiration event:

Termination of Services

End of Plan Year

Specific Date

End of Plan Year Date(Required)

Specific Date(Required)

Signatures

Service User's First Name(Required)

Service User's Last Name(Required)

Service User's Email

Date(Required)

Authorized Representative First Name(Required)

Authorized Representative Last Name(Required)

Authorized Representative Email

Date(Required)

Relationship to Service User Description of Authority to Act

Address of Legally Authorized Representative

Street Address Address Line 2 City State ZIP Code

Phone Number of Legally Authorized Representative

Witness First Name

Witness Last Name

Witness Email

Witness Initials

Date

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by this written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2.

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