HIPAA Authorization for Substance Abuse Treatment Records

Patient Name:

Date of Birth:

Patient ID/Record #:

Provider/Facility Authorized to Disclose Information: Recipient/Organization to Receive Information: Description of Information to be Disclosed: Purpose of Disclosure:

Expiration Date or Event:

Date of Authorization:

Patient Rights

I understand that my records are protected under federal regulations (42 CFR Part 2 & HIPAA) and cannot be disclosed without my written consent unless otherwise permitted.
I may revoke this authorization at any time by notifying the provider in writing.
I understand that revocation will not affect actions taken prior to revocation.
I understand that I am not required to sign this form for treatment, payment, or eligibility for benefits.

Signature of Patient:

Date:

If signed by patient’s legal representative, indicate relationship: