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ROI - NJ Release of Confidential Information
LifeBack
4 Princess Rd
Suite 206
Lawrenceville, New Jersey 08648
Phone 609-482-3701
Fax 609-482-3702
Client Information
First Name:
*
Last Name:
*
Date of Birth:
*
Birth Sex:
*
Address:
City:
State:
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Zip Code :
Phone No:
* I authorize LifeBack to disclose information to and/or obtain information from:
Include the name of the recipient and/or agency where applicable.
* Phone #
* Fax, email, or other contact information
If not applicable write "N/A or None"
* I approve the following information to be released or obtained:
Yes
No
Presence/Participation in Treatment
Yes
No
Progress and Prognosis
Yes
No
Counseling Assessment
Yes
No
Psychiatric Evaluation
Yes
No
Treatment Plan/Treatment Goals
Yes
No
Diagnosis
Yes
No
Medication and Medical Information
Yes
No
Discharge Summary/Continuing Care Plan
Yes
No
Scheduling
Yes
No
Medication Refills
Yes
No
Other
* The purpose for the disclosure of this information is to:
Yes
No
Coordinate care with other treatment provider(s)
Yes
No
Coordinate with parent(s)/guardian(s)
Yes
No
Satisfy employment requirements
Yes
No
Satisfy school requirements
Yes
No
Satisfy legal requirements
Yes
No
Other
* Expiration: Unless sooner revoked, this authorization is effective on the date signed below and expires on
NOTE: expiration date cannot exceed 365 days after date of signature.
Patient information will not be used/sold for sales, marketing and/or research purposes.
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.
Conditions:
I understand that LifeBack will not condition my treatment on whether I give authorization for the requested disclosure and if any treatment conditions are contingent upon my authorization this information will be fully explained to me and documented.
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.
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.
Understanding:
I am aware I can request a copy of this authorization for my records. I am aware that I have a right to inspect materials released. By signing below, I am indicating that I understand the nature of this release.
* Electronic Signature
I understand that by typing my name below and clicking "Submit," I am electronically signing this document.
* Relationship to Patient
If you are signing as a parent, guardian, or personal representative of the Patient, please indicate relationship or authority. TYPE N/A IF NOT APPLICABLE
* Date
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