RE: SSN: Consumer name Date of Birth: Address City, state, zip I, , hereby authorize the disclosure of personal Consumer’s name or protected health information about me by: Covered Entity’s Name: Address: City, State, Zip: I understand that signing this form will not interfere with my treatment, payment, enrollment or eligibility for benefits from this provider. The protected health information shall be disclosed to: Office of Vocational Rehabilitation Counselor name: Office address: City, State, zip: I understand that the use and purpose of this disclosure is to determine my eligibility for and/or the nature and scope of vocational rehabilitation services on my behalf. The specific type of information to be disclosed is: 4. If the information requested is from an alcohol or drug treatment case, 42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records applies: This information has been disclosed to you from records protected by Federal confidentiality rules. The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization of the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. This form authorizes the release of health information including HIV-related information. You may choose to release only your non-HIV health information, only HIV-related information, or
RE: SSN: Consumer name Address Date of Birth: City, state, zip I, , hereby authorize the disclosure of personal Consumer’s name or protected health information about me by: Covered Entity’s Name: Address: City, State, Zip: I understand that signing this form will not interfere with my treatment, payment, enrollment or eligibility for benefits from this provider. The protected health information shall be disclosed to: Office of Vocational Rehabilitation Counselor name: Office address: City, State, zip: I understand that the use and purpose of this disclosure is to determine my eligibility for and/or the nature and scope of vocational rehabilitation services on my behalf. The specific type of information to be disclosed is: 4. If the information requested is from an alcohol or drug treatment case, 42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records applies: This information has been disclosed to you from records protected by Federal confidentiality rules. The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization of the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. This form authorizes the release of health information including HIV-related information. You may choose to release only your non-HIV health information, only HIV-related information, or
authorizehealthrelease.docx