(If there are multiple parties, please use a separate form for each party)
(If none listed, all records will be included)
Please choose at least one of the following:
I understand that my records may contain information regarding mental health diagnosis and treatment, drug and/or alcohol abuse, the testing, diagnosis, or treatment of HIV/AIDS and/or sexually transmitted diseases. I give my specific authorization for these protected records to be released. Any of these records I do not want released are listed below.
You have a right to revoke this authorization in writing at any time by providing such written notification to Rainier Behavioral Health. However, your revocation will not be effective to the extent that Rainier Associates, or another party, has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest the claim. I understand that Rainier Behavioral Health, my health plan, nor other covered entity may condition treatment, payment, enrollment, or eligibility of benefits upon my signing this authorization for release of information. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of this information and no longer protected by the HIPAA privacy rule. This release shall remain in effect for 90 days unless otherwise specified.
** By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
*Minors~ A minor’s signature is required to release the following information: 1) conditions relating to reproductive care including, but not limited to birth control and pregnancy-related services and sexually transmitted diseases, including HIV/AIDS, (age 14 and older) substance abuse diagnosis or treatment and mental health conditions (age 13 and older).