Center Associates - Release of Information to Physician

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AUTHORIZATION TO RELEASE/OBTAIN INFORMATION

Mental health information may only be disclosed pursuant to the written authorization of the client or the client’s legal representative or as otherwise provided in Chapter 228, Code of Iowa.  Any unauthorized disclosure of mental health information is unlawful and is subject to civil damages and criminal penalties.  This release is requested for the following purpose(s): (1) To communicate and share information to provide efficient, effective treatment; (2) To establish a basis for determining eligibility for disability or other entitlement programs; (3) To make referrals; and/or (4) To communicate and share information at the request of the client.

This authorization is voluntary and expires 12 months from the date of my signature.  If I choose to cancel this consent prior to the expiration date, I must provide written notification to Center Associates.  If this consent is cancelled, I understand that information may have been released prior to the cancellation, and that action would not be considered a breach of confidentiality.  I also acknowledge that: 1) recipients of this information may possibly re-release the information without proper authorization, and 2) once information is disclosed it may no longer be protected by federal privacy regulations.  I understand that I may review the disclosed information.  Any questions may be directed to the Center’s Release of Information department.

Center Associates does not require completion of this form as a condition of evaluation or treatment.  However, when the provision of services is solely for the purpose of research related treatment or creating information for disclosure to a third party, refusal to sign may result in denial of those services. 

I authorize Center Associates, either verbally or in writing, to release and/or obtain information from:

Release/obtain the following information

Center Associates is a mental health agency and by signing this form I understand that I will be releasing mental health information.  Additionally, I agree to release information in the following categories (initial what information you DO allow to be released):

Relationship *
 
Signature (Electronically signed by) *
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