PATIENT HIPAA COMMUNICATION FORM

A. Family & 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:

1. Parent/legal guardian
2. Other persons authorized by the patient,
3. In emergency situations, or
4. 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 a family member, friends, or caregiver/babysitter. 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.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

*** It is patient's responsibility to fill out form completely, if you leave information blank and sign prior information will remain the same and not update. You will be responsible for any claims denied due to this ***