Substance Abuse Treatment Records Release

Patient Information

Name

Date of Birth

Phone Number

Release Details

Release Substance Abuse Treatment Records FROM (Provider/Facility Name) Provider/Facility Address Provider/Facility Phone Release records TO (Individual/Organization Name) Recipient Address Recipient Phone

Information to be Released

If Other, specify Purpose of Disclosure

Authorization Period

Effective Date

Expiration Date/Event

Patient Rights & Signature

I understand I may revoke this authorization at any time by notifying the provider in writing. This authorization is voluntary, and I understand that my treatment or payment for services will not be affected if I do not sign this form. I understand that information disclosed as a result of this authorization may be re-disclosed by the recipient and may no longer be protected by privacy laws.

Patient Signature

Date

If patient is a minor or lacks capacity, Representative's Name/Relationship

Representative Signature

Date