Disclosure to Self and to Others

Please correct the errors described below.

A. FAMILY AND FRIENDS: It is the office policy of Advanced Behavioral Health Center not to release confidential medical information regarding your treatment to family members or friends, except for (i) parent/legal guardian, (ii) other persons authorized by the patient, (iii) in emergency situations, or (v) as otherwise permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you anticipate that you will need or want your medical information to be provided to family members, friends, or caregivers/babysitters, please indicate that below, so that we may best serve you. By signing below, you authorize the following persons to receive information as requested, regarding your care and treatment. Updates to this form must be made in person.

B. ALTERNATIVE COMMUNICATION: I wish to be contacted in the following manner.

(check all that apply)

DISCLAIMER: By typing or writing your name below, you agree with the HIPAA form. It is the patient's responsibility to fill this out completely. If you leave the information blank and sign, this will remain the same and not update. You will be responsible for any claims denied due to this.

Your information will be encrypted.