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NJ Release of Confidential Information
LifeBack
4 Princess Rd
Suite 206
Phone 609-482-3701
Fax 609-482-3702
Client Information
First Name:
*
Last Name:
*
Date of Birth:
*
Gender:
Non-binary
Multi-gender
Poly-gender
prefer not to disclose
Ambiguous
Female
Male
NOT APPLICABLE
OTHER
Transgender (Female Pronouns)
Transgender (Male Pronouns)
Unknown
*
Address:
City:
State:
Select A State
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District of Columbia
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Alberta, Canada
British Columbia, Canada
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Prince Edward Island, Canada
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Saskatchewan, Canada
Yukon, Canada
Australian Capital Territory, Australia
Jervis Bay Territory, Australia
New South Wales, Australia
Northern Territory, Australia
Queensland, Australia
South Australia, Australia
Tasmania, Australia
Victoria, Australia
Western Australia, Australia
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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