I understand the information to be released may include records related to behavior and/or mental health, alcohol/drug abuse treatment, HIV/AIDS, and genetics. This authorization may be revoked at any time except to the extent that action has been taken in reliance upon it. I may do so by sending written notice to the Office Manager, Hope Springs Behavioral Consultants, 1303 5th St Ste. 202, Coralville, IA 52241-2939. I understand that any release that was made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to confidentiality.
Disclosure of this information carries with it the potential for unauthorized re-disclosure, and once information is disclosed it may no longer be protected by federal privacy regulations. I understand that I may review the disclosed information or ask questions by contacting the Office Manager at the above address. I may be charged for copies in accordance with state law.
I understand that Hope Springs Behavioral Consultants may not require completion of this form as a condition of treatment. However, when the provision of services is solely for the purpose of creating a medical report (protected health information) for a third part, refusal to sign may result in a denial of those services.
This agreement will expire one year from the date of signature, unless previously revoked or otherwise indicated.
ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form.
- If the patient is 18 years of age or older, the patient must sign and date this form.
- If the patient is 18 years of age or older and incapable of signing, a legally authorized substitute may sign and date this form.
- If the patient is 17 years of age or younger, the patient’s parent or legal guardian must sign and date this form, unless an exception exists under state of federal law.