Release of Info – Family Connections

AUTHORIZATION TO OBTAIN OR RELEASE CONFIDENTIAL INFORMATION

I hereby authorize Family Connections, LLC to: *

Obtain From:
Release to:

Agency/Provider

Address

Address Line 1

City

State

Zip Code

Phone *

Client's Name *

Date of Birth

CONFIDENTIAL INFORMATION *

Mental health information including psychosocial history/assessments, psych testing, psychiatric and psychological evaluations, treatment plans, discharge summaries.
Education information, including Permanent Record Card, academic evaluations, psych and educational testing, educational recommendations and vocational assessments. MDT reports and IEP’s.
Medical information including but not limited to physical exams, health history, immunization records, lab results, medication history.
Other information pertinent to treatment planning:

Other information pertinent to treatment planning:

The information shall be obtained and / or released via: *

Verbal Exchange
Mail
Confidential Fax
In Person

To cover the following time periods: from ____________ to ____________ or date of discharge. *

The information shall be used for the purpose of *

Evaluation and Assessment
Treatment Planning
Coordination & Consultation with other Treatment Providers

I understand that the information obtained/released under this authorization is protected by laws regarding confidentiality of the State of Rhode Island. I further understand that this authorization will automatically expire one year from the date of signing and that it may be withdrawn by written request at any time. I release Family Connections, LLC from any liability that may arise in connection with obtaining and/or releasing this information, provided that said release of information is done substantially in accordance with applicable law. A photocopy of this authorization is as valid as the original.

I understand that my records are protected under Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records 42 CFR and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I have read and understand the purpose of this release and am signing this authorization voluntarily. I understand that I may revoke my consent at any time except to the extent that action has been taken in reliance upon it. *

I understand

Name of Client *

First

Last

Signature of Client *

Clear Signature

Date *

Name of Parent/Guardian

Signature of Parent/Guardian

Clear Signature

Date

Name of Witness

Signature of witness

Clear Signature

Date

Clinician's Email *