Release Of Information

Authorization for BYS to share information about a clinic client with a third party.

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This field is for validation purposes and should be left unchanged.

Client name(Required)

First Last

Birth Date(Required)

This authorization is between Bainbridge Youth services (BYS) and(Required)

Relationship to client(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Email(Required)

I authorize BYS to disclose information to above party

I authorize BYS to obtain information from above party

This release allows the disclosure of Protected Health Information, specifically including mental health/psychological treatment (45 CFR Parts 160 and 164); drug/alcohol treatment (42 CFR Part 2); and sexually transmitted disease treatment/HIV/AIDS (RCW 70.02.220).

Protected Information as stated above NOT authorized (if applicable):

This information has been disclosed to you from records whose confidentiality is protected by state or federal law. These laws prohibit you from making any further disclosure of it without the specific written authorization of the person to whom it pertains, or as otherwise permitted by law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

Other limitations on disclosure (if applicable):

Purpose of disclosure:(Required)

Treatment planning/continuity of care

At the request of the client

Other

This authorization expires at the end of services with this provider, or as specified:

CONSENT OF A MINOR: A minor's (age 13-17) signature is REQUIRED in order to release information concerning that minor's mental health or substance treatment. A minor's (age 14-17) signature is required in order to release information relating to the minor's information related to sexually transmitted diseases. I understand that: - Authorizing disclosure of PHI is voluntary, and not signing will not impact receiving treatment. - This authorization covers verbal, paper, and electronic disclosures. A copy or fax of this form is considered valid in lieu of original. - This release may be revoked, in writing, at any time unless BYS has already disclosed the information, and will not apply where regulations require access to the information. - Any disclosure of information carries with it the potential for further release of distribution by the recipient that may not be protected by confidentiality laws.

Signature(Required)

Enter complete legal name for electronic signature

Date signed(Required)

Release Of Information

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