Authorization for Use and Disclosure of Protected Health Information This authorization form implements the requirements for client authorization to use and disclose health information protected by the federal health privacy law (45 CFR 160, 164), the federal drug and alcohol confidentiality law (42 CFR 2), and the disabilities and substance abuse services (GS 122C).
Sandhills BEST Care
INTERNAL Office Use Only
Client Name: _________________________________
DOB: ________________ Record #: _________________
Staff Witness Signature: _________________________
Date: _________________
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give Sandhills Best Care, authorization to communicate with, obtain health records from and share health records and information with the following providers and/OR schools:
Redisclosure Once information is disclosed pursuant to this signed authorization, I understand that the federal privacy law (45 CFR 160, 164) protecting health information may not apply to the recipient of the information and therefore may not prohibit the recipient from disclosing it. Other laws, however, may prohibit disclosure. When we disclose mental health and developmental disabilities information protected by state law (GS 122) or substance abuse treatment information protected by federal law (42 DFR 2), we must inform the recipient of the information that disclosure is prohibited except as permitted or requested by these two laws.
Revocation and Expiration I understand that with certain exceptions, I have the right to revoke this authorization at any time. The procedure of how I may revoke this authorization, as well as the exceptions to my right to revoke, have been explained to me. If not revoked earlier, this consent shall be valid for one year from the date signed unless otherwise indicated below:
Notice of Voluntariness I understand that I may refuse to sign this authorization form.
