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LifeBack
4 Princess Rd
Suite 206
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* I authorize LifeBack to disclose to and/or obtain from (include name of person, facility, or agency)    
* Phone #
Fax, email, or other contact information
the following information:
Assessment   Diagnosis   Psychosocial Evaluation  
Psychological Evaluation   Psychiatric Evaluation   Treatment Plan/Summary  
Current Treatment Update   Medication Management Information   Presence/Participation in Treatment  
Nursing Medical Information   Toxicological Reports/Drug-Screens   Educational Information  
Discharge/Transfer Information   Continuing Care Plan   Progress in Treatment  
Demographic Information   Other   Other  
Psychotherapy Notes (Cannot be combined with any other disclosure)     
The purpose for this disclosure of information is to:
Coordinate care with other treatment provider(s)   Satisfy employment requirements   Satisfy legal requirements  
Satisfy school requirements   Other    
Revocation: I understand that I have a right to revoke this authorization at any time by providing written notification to the Clinical Director of LifeBack. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
* Expiration: Unless sooner revoked, this authorization is effective on the date signed below and expires on    
Conditions: I further understand that LifeBack will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:    
Form of Disclosure:
Unless you have specifically requested in writing that the disclosure be made in a certain format, LifeBack reserves the right to disclose information as permitted by this authorization in any manner deemed to be appropriate and consistent with applicable law including, but not limited to, verbally, in paper format, or electronically.

PT information will not be used/sold for sales, marketing and/or research purposes.

Redisclosure:
I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections.

Federal law 42 C.F R. Part 2 prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.FR Part2.

I will be given a copy of this authorization for my records.
Signature of Client
Name:
Signature:
Sign on ePad
Signature for Web Forms
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
Signature of Parent, Guardian or Personal Representative
Name:
Signature:
Sign on ePad
Signature for Web Forms
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
If you are signing as a personal representative of an individual, please describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.):    
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