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PA MH ROI #1

LifeBack
4 Princess Rd
Suite 206
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
I authorize LifeBack to    Select ONLY one - Release OR Obtain
Release information to:  
Obtain information from:  
* Name of person, facility, or agency
Address
Phone #
Fax, email, other contact information
the following information:
Assessment   Diagnosis   Psychiatric Evaluation  
Treatment Plan   Progress in Treatment   Medication Management Information  
Presence/Participation in Treatment   Medical Information   Lab/Screening Results  
Discharge Summary   Continuing Care Plan   Demographic Information  
Other   Other    
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   Coordinate with parent(s)/guardian(s)   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    NOTE: expiration date cannot exceed 365 days after today’s date.
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:    
Patient information will not be used/sold for sales, marketing and/or research purposes.

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.

I am aware I can request a copy of this authorization for my records.
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Signature:
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Comments:
Signature for Web Forms
Signer Type:
Name:
Signature:
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Comments:
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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