Substance Abuse Treatment Records HIPAA Authorization

This form authorizes the use or disclosure of substance abuse treatment records as required by the Health Insurance Portability and Accountability Act (HIPAA).

Patient Information

Patient Name

Date of Birth

Address

Phone Number

Release Information From

Provider / Facility Name Address

Release Information To

Recipient Name / Organization Recipient Address

Information to be Disclosed

Purpose of Disclosure

Expiration

This authorization will expire on (date or event):

Patient Rights

I understand that I may revoke this authorization at any time in writing.
I understand that a revocation is not effective for disclosures already made.
I am not required to sign this authorization in order to receive substance abuse treatment services.

Patient Signature

Date

Legal Representative Signature (if applicable)

Date

Relationship to Patient (if legal representative)