NextStep

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	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	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 Expiration date cannot exceed 365 days

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.

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 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