ACP Release of Information

This form can only be used for ONE organization. It is NOT valid if two organizations are listed for communication.

If you need additional forms for contact with multiple organizations, please contact our office at 330-264-9597. Thank you!

Client First Name

Client Middle Initial

Client Last Name

Client Date of Birth (MM/DD/YYYY)

Client Social Security Number (###-##-####)

I hereby authorize Anazao Community Partners to:

Provide to and Receive from

Other

please see next box (must be checked to see options)

Other Organization to communicate with:

List ONLY ONE organization per form. If additional forms are needed, please call the office at 330.264.9597. Only complete if answered "Other" in previous field.

The following minimum necessary information:

All Records

No need to check other options.

Other

Options available when checked

Other Options:

Admission Summary and/or Assessment and Diagnosis

Attendance and/or Treatment Engagement

Progress and/or Treatment Summary

Recommendations and/or Discharge Summary

Educational Records

Other

Please list other reasons in next box (appears when this box checked)

Other Information to be Released:

I understand this authorization is voluntary and the information, which I have the right to review, will be used for the following purpose and no other:

Continuity of Care

Other

Options available when checked.

Other Options

To Coordinate Treatment

To Obtain Assessment Information

To Obtain Treatment Information

Other

Please list other reasons in next box (which will appear when this box is checked)

Other Reason for Release:

The amount of minimum necessary information to be released is:

All Treatment Episodes

Other Option

Other Options

Most Recent Treatment Episode

Treatment within the Past 6 Months

I consent to information being released in the following manner:

Electronic, Verbal, and Hard Copy

Other

Other Options

Electronic (i.e. Fax, Encrypted Email)

Verbal

Letter, Memo, or other hard copy

I expressly consent to the release of information designated above. I understand and acknowledge that this authorization extends to all or any part of the records designated above which may include treatment for mental illness (ORC 5122) and/or substance use (42 CFR Part II). Refusal to consent means that the information will not be requested or released. I understand that my care and payment for my care will not be affected without a release of information, but that refusal may hamper further evaluation and treatment. If no date, event or condition upon which consent will expire is noted, this consent will expire 90 days from the signing of the authorization. I have read and fully understand the content of this form, or this has been fully explained to me in a language that I understand. I understand that information disclosed to the recipient may no longer be protected by HIPAA and/or 42 CFR II.

Consent

Grant Consent

Information will be released or requested.

Refuse or Revoke Consent

Information will not be released or requested.

Authorization Expiration

Extend authorization for the current treatment episode.

No need to complete an additional release for this organization. Release will expire on Discharge.

Extend authorization for 1 year from signature date.

Release is only authorized for 90 days from signature date.

Client Electronic Authorization (if 18+) or Parent/Guardian (if Client is under 18)

Date

Notice regarding non-residential parents: A non-residential parent is entitled to any record that is related to the child unless the court determines and issues an order that it would not be in the best interest of the child for the non-residential parent to have access to the records. (ORC 3109.051)

For requested/requesting organization only: Prohibition against redisclosure: This information has been disclosed to you from records protected by federal confidentiality rules which prohibit you from making any further disclosures of this information unless expressly permitted by consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part II. A general authorization for the release of medical or other information is not sufficient for this purpose. Federal rules restrict any use of information to criminally investigate or prosecute any substance use consumer. (These conditions apply to all information disclosed.) Notice of receiving agency/person: Under the provisions of the Ohio Mental Health and Developmental Disabilities Confidentiality Act, you may not disclose any of this information unless the person who consented to this disclosure specifically consents to such redisclosure.

Your information will be encrypted.