Authorization to Release and Obtain Protected Health Information
Client First Name
Client Last Name
Client Date of Birth
I do hereby consent to authorize Diversus Health to (check all that apply)
Get information from and/or
Release private (confidential) information to the following person(s) and/or entity
All my treating providers, staff or representative at
Enter name of organization or individual (one organization/individual per authorization)
Full Address (Street address, City, State, Zip)
Address of Organization/Individual you are authorizing Diversus Health to exchange information with
Phone number of Organization/Individual you are authorizing Diversus Health to exchange information with
Fax number of Organization/Individual you are authorizing Diversus Health to exchange information with
Email of Organization/Individual you are authorizing Diversus Health to exchange information with
Information To Be Released
The information that can be obtained/disclosed under this authorization includes the following
Check ONLY the information you authorize Diversus Health to exchange with the Organization/Individual you entered above. If you do not see a choice below, please enter the information in the empty field provided.
Person Centered Plans/Treatment Plans
Psychiatric Evaluations/Medication Reviews/Labs
Information Related to Benefits or Insurance
Work Related Information
The information may be released by (check all that apply):
Electronic (Email, Fax, Upload)
Purpose of the Release (check all that apply)
To provide comprehensive case coordination
To determine eligibility for services
At the request of the individual
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).
I authorize the release of information relating to referral and/or treatment for alcohol and drug abuse
I PROHIBIT the release of information relating to referral and/or treatment for alcohol and drug abuse
HIV/AIDS/Sexually Transmitted Disease/Communicable Disease
I authorize the release of information relating to HIV/AIDS/sexually transmitted disease/communicable disease
I PROHIBIT the release of information relating to HIV/AIDS/sexually transmitted disease/communicable disease
Terms and Conditions
I understand that:
-The requested information may not be protected from re-disclosures by the parties it is released to and is no longer protected under federal privacy laws; however, if this information is protected by the Federal Substance Abuse Confidentiality Regulation (42 CFR part 2), the party this is disclosed to may not re-disclose such information without my further written authorization provided for by state or federal law.
- Substance Use Disorder related information can be released in the event of a bona-fide 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 have a copy of this authorization.
- I may revoke this authorization at any time by notifying Diversus Health Medical Records in writing or by signing the revocation form. Any revocation is for future releases and does not apply to any releases made prior to the revocation date.
- This authorization is not for the disclosure of psychotherapy notes, as Diversus Health does not maintain psychotherapy notes as part of the medical records.
If client is over 12 years old, client must sign
Signature of Client, Legal Guardian or Representative
Upload Photo ID of client, Legal Guardian or Representative