Extra ROI Form – Behavioral Health

Native American Community Health Center, Inc

AUTHORIZATION TO RELEASE / OBTAIN PROTECTED HEALTH INFORMATION

Form # 840.C.April 14,2003, Side A, revised 05/2021

1. The above identified individual, authorize NATIVE AMERICAN COMMUNITY HEALTH CENTER, Inc. and the following facilities:

To release / obtain medical information from my medical record to / from:

CLIENT NOTICES

1. Federal law and regulations protect the privacy & confidentiality of alcohol and/or drug abuse client records, maintained by Native Health. Except under special circumstances, Native Health may not orally disclose to a person outside the program that a client attends the program. The program also may not disclose any information identifying the client's history of alcohol and/or drug abuse unless: by written authorization by the client; by written court order; or the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation process. (Federal Law references 45 U.S.C. Privacy, 164, 42 U.S.C. 290 dd-3 and 42 U.S.C. 290 ee-3 - Federal Regulation reference CFR, Part 2)
2. I authorize Native Health to disclose medical information regarding my treatment at Native Health to include any protected health information to the entity as indicated on this authorization form. This disclosure is necessary for continuity of care. I understand that federal law protect the confidentiality of my alcohol and drug abuse medical records. I understand that I can revoke this authorization at any time in writing and that this authorization is valid for a six(6) month period from the date of my signature / or until 90 days post discharge.
3. I understand that my protected health information (medical history) may be used and disclosed to carry out treatment, payment of service, or health care operations to improve quality of care by Native Health and other medical professionals that provide care to me.
4. I acknowledge receipt of Native Health Notice of Privacy Practices and I understand that I have the right to review the Notice before signing the consent. I understand and changes in the Notice are available to me upon request.
5. I understand that I have the right to request Native Health to restrict how my protected health information is used or disclosed to carry out treatment, payment, or health care operations. I understand that Native Health is not required to agree with my request.
6. I understand that I have the right to revoke an authorization to release my protected health information in writing.

Notice to Recipient: you are receiving this information, from records that are private, confidentiality and protected by Federal law. Federal regulations (42CFR Part 2 and 45 CFR Section 164) prohibits you from making any further disclosure of it without this specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.

Client Signature

Legal Representative Signature

Witness Signature