FORM – Release of Information Emergency Contact

I hereby authorize Refreshing Waters Counseling to release my information to:

Released to name

Field Group Open

Name*

Email*

Phone*

Relationship*

Field Group Close

Patient's First Name*

Patient's Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Date of Birth*

MM

DD

YYYY

Field Group Open

I authorize the following information to be released to my emergency contact for all dates of service*

I authorize the following information to be released to my emergency contact for all dates of service

Field Group Close

I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon this authorization. If not previously revoked, this authorization will terminate on the following date, event, or condition

Date*

If no date, event, or condition is specified, this authorization will expire after 1 year.

I further understand that I will agree to pay the facility the costs incurred by Refreshing Waters Counseling & Consulting in preparing the copy of the requested mental/behavioral health records as allowed by State and Federal guidelines.
I understand that no treatment, payment, enrollment, or eligibility for benefits may be conditioned on whether I sign this authorization.
The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
The information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected by federal law, except for drug and alcohol treatment information.
I understand that I am entitled to a copy of this authorization.
I understand that my alcohol and/or drug treatment records are protected under Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. Parts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been