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FORM – Release of Information

Home/FORM – Release of Information
FORM – Release of Information2020-04-20T14:02:21-04:00
  • I hereby authorize Refreshing Waters Counseling to release my information to:

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • 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

  • If no date, event, or condition is specified, this authorization will expire after 1 year from last date of service.

  • Date Format: MM slash DD slash YYYY
    • 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 taken in reliance on it, and that in any event this consent expires automatically as follows.

  • Date Format: MM slash DD slash YYYY

Phone: 734-794-3777
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2723 South State St. Suite 150
Ann Arbor, MI 48104
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