Authorization to Release Health Information (ROI)

All sections with asterisks are REQUIRED. Incomplete ROIs will not be processed.

I understand that authorizing the disclosure of the above information is voluntary and I understand that the information in my health record may include records relating to sexually transmitted diseases, drug and/or alcohol abuse treatment, psychiatric and mental health care, or other sensitive information. I understand that if I am seeking behavioral health services, that the entity seeking this authorization will not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign the authorization. I also understand that if I am seeking Drug and Alcohol Services subject to 42 C.F.R Part 2, that the entity seeking this authorization is not permitted to condition treatment, payment, enrollment or eligibility for benefits on the provision of a 42 C.F.R Part 2 compliant release for treatment purposes. I understand that I may request a copy of this authorization. I understand that a photocopy/fax of this authorization is as valid as the original. I understand that there may be a fee for copying associated with this request. I understand that I have the right to revoke this authorization at any time except to the extent that information has already been released. Authorizations for the release of alcohol and drug abuse records protected by 42 C.F.R. Part 2 can be revoked verbally. Authorizations covering all other health information must be revoked in writing. I hereby authorize the use or disclosure of the health information as described above.

Prohibition On Redisclosure: I understand that information only covered by HIPAA (45 C.F.R. Parts 160 & 164) is subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Act. I understand that health information covered by federal law 42 C.F.R. Part 2 (Alcohol & drug abuse records prohibits any further disclosure of information that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see §2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65. 42 C.F.R. Part 2 prohibits unauthorized disclosure of these records.

REVOCATION SECTION

DO NOT complete this section when the authorization is initially signed. Only complete if the Participant wishes to revoke this authorization. I hereby request that this authorization to release information be revoked, effective on the date of my signature below.

If Participant revokes verbally, Employee will enter their name and job title followed by the date the Employee received the revocations instructions.

BWC Employee Use Only:

Revised 04/25/24