Authorization to Release Protected Health and Behavioral Protected Health Information

  Authorization to Release Protected Health and Behavioral Protected Health Information
Client Infomation
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Agency and Release Information
I do hereby consent to authorize Diversus Health to (check all that apply) *
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Transmission Modes (How records may be released) check all that apply *
Information To Be Released * 🛈
 
DUI ONLY - information that can be obtained/disclosed under this authorization includes the following: 🛈
Purpose of the Release  Check all that apply *
 
Additional Information
Please note – The records released may contain alcohol and drug abuse information and/or information about Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), and AIDS Related Complex (ARC).
  Alcohol/Drug Abuse *
HIV/AIDS/Sexually Transmitted Disease/Communicable Disease *
I understand that:
Information disclosed based on this Authorization, except for information about a substance use disorder, may be re-disclosed by the recipient and no longer be protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (45 CFR part 164). Records about a substance use disorder will continue to be protected under federal rules following disclosure and cannot be disclosed or re-disclosed without my written consent unless otherwise provided for in the relevant rules (42 CFR part 2).
 
I cannot be required to sign this Authorization as a condition of treatment, payment, enrollment, or eligibility for benefits.  Diversus Health may not refuse to treat me if I refuse this Authorization unless this Authorization is necessary for my participation in a research study, or the purpose of the treatment is to provide information to the individual/entity identified in this Authorization.
 
Substance Use Disorder-related information can be released in the event of a bonafide medical emergency without consent.
Under 42 CFR Part 2, I have the right to request a list of disclosures to which disclosures have been made pursuant to the general designation - For 42 CFR Part 2 violations, I can contact the US Attorney for Colorado at 1801 California Street, Suite 1600, Denver, CO 80202, 1-303-454-0100
 
Diversus Health has no control over this information after it is released and is not liable for any other disclosures.
 
I may revoke (cancel) this authorization at any time by notifying Diversus Health Medical Records in writing or by signing the revocation form. If not revoked, this Authorization will expire two (2) years from the date I sign it unless a date is specified below
 
This authorization is not for the disclosure of psychotherapy notes, as Diversus Health does not maintain psychotherapy notes as part of the medical records.
 
My signature below means I understand and accept the terms of this Authorization. A copy of this Authorization (including fax) is as valid as the original. I have a right to receive a copy of the signed Authorization.
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Signature of Client, Legal Guardian or Representative *
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If client is over 12 years old, client must sign
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