I understand by completing this form I authorize:
Judy Retterath Withdrawal Management Center
3409 East Medicine Lake Blvd
Plymouth MN 55441
Phone: 763.559.1402
Fax: 763.559.2559
To release information to and obtain information
from the organization/person indicated on this form.
I understand that if a general destination is used, I may request to be provided a list of entities to which my information has been disclosed pursuant to the general destination.
I authorize disclosure of information that refers to treatment and/or diagnosis of alcohol and/or drug abuse.
I understand information disclosed cannot be re-disclosed without my written consent.
My records are protected under Federal and State law and cannot be released without my written permission or a court order. I may revoke this consent in writing at any time.
I understand the revocation will not have any affect on any actions the entity took before it received the revocation.
Refusal to disclose information may result in improper diagnosis, treatment, and/or denial of coverage for a claim for health benefits or other insurance, or other adverse consequences.
My refusal to sign this authorization will not affect my ability to obtain treatment, benefits or services for which I am eligible.
I am entitled to a copy of this release of authorization form.
I understand signing this form is voluntary.
I understand that my records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Records, 42 CFR art 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations.
I also understand 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 60 days after the date I signed the consent.
CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
I understand that my substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 CFR
Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 CFR Parts 160 and 164, and cannot be redisclosed without my written consent unless otherwise provided for by the regulations.
I understand that this information will be used in accordance with Federal and State Confidentiality Laws.
A general authorization for the release of medical or other information is NOT sufficient for this purpose.
The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug patient.
