Client Consent - Release of Information Form
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First Name *
Last Name *
Date of Birth *
I hereby give my consent for release of pertinent information for treatment enrollment/progress to Step Up Counseling of Boerne to and from __________. (Choose all that apply) *
Required
For each box checked above, list the name and the email address of contact you're allowing release of information to and communication with. *
Information to be disclosed: evaluation report, recommendation, progress notes, discharge report and other communication deemed necessary.
For the purpose of: PROBATION/COURT CASE - CASE MANAGEMENT
I understand that my records are protected under the federal regulation governing Confidentiality of Alcohol and Drug Abuse Patient Records 42 CFR Part 2, and HIPAA of 1996, 45CFR pts 160 & 164, & cannot be disclosed without my written consent unless otherwise provided for in the regulations. This authorization may be revoked at any time except to the extent that action has been taken in reliance on it and will remain in effect until program completion. Authorizations to Courts may not be revoked.
By signing, I agree that each of the above entities can exchange information related to my treatment that is deemed necessary.  By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. *
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