Consent for the Release of Information
By signing below, I hereby authorize Atlanta Intervention Network to release and receive the following information:
a. an alcohol and drug evaluation along with recommendations,
b. plus the following (if applicable - see B. below):

I further understand that this information release will be limited to only information which is necessary for effective case management and/or treatment.

I further understand that I may revoke my consent at any time by delivery of a written notice to Atlanta Intervention Network. It will be effective upon the date the notice is received but will excluded information furnished prior to this date. In the absence of my formal written notice, this consent is revoked automatically on whichever comes first: 6 months from the date below or the completion, release, transfer, or discharge date.

TO THE RECIPIENT OF THIS INFORMATION:
This notice accompanies a disclosure of information concerning a client in alchol/drug treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from kaing 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 for 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.

Atlanta Intervention Network
PO Box 1003, Conyers, GA 30012
Phone: 770-602-1979
Fax: 770-860-8315
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B. any other information I authorize to release:
Your First Name *
Your Last Name *
Today's Date *
MM
/
DD
/
YYYY
To: (please type in the person's title or position as well as their first and last name) *
Organization to which we are sending the information: *
Address of person to which we are sending the information:
Telephone number of the person to which we are sending the information:
Fax number of the person to which we are sending the information:
Please check the box to confirm your release: *
Required
Please type your first and last name below as your electronic signature: *
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