Download Consent For Release Form - Windward Behavioral Care

AUTHORIZATION TO RELEASE
CONFIDENTIAL INFORMATION
RE:
Client Name
This will authorize Business
Date of Birth
-
Archives, Inc. who is Acting
Social Security
Records Administrator for Windward Behavioral Care,
Inc.to disclose my Protected Health Information in accordance with Florida Statutes: 394; 396, 397,381.609,415,455,490 and 916 and
(42 CFR Part 2). Business Archives is acting as the Authorized Representative for Windward Behavioral Care, Inc. which is now a
dissolved agency. I understand that this authorization extends to all or any part of the records designated, which may include
psychiatric information and or alcohol/drug abuse, TB and or STD and or documented proof of HIV testing, AIDS (Acquired
Immunodeficiency Syndrome) diagnosis information. A general medical authorization and subpoena duces tecum, without a specific
authorization to release records as mentioned must have this waiver from the client or his/her empowered representative.
Information may be disclosed to:
Name of Agency/ Individual to Whom the Records will be disclosed
Address: City,State, Zip:
Fax:
EMAIL Address:
Telephone Number:
Note: payment for disclosure is the responsibility of the agency/individual requesting information. Please call number below for cost.
Prohibition on Re-Disclosure
Alcohol and drugs, Mental Health and or HIV, ARC and/or AIDS diagnosis information if present, has been disclosed from records
whose confidentiality is protected by Florida State and Federal Law. Federal regulations (42CFR part ) prohibit making any further
disclosure of it without the specific written authorization of the undersigned or as otherwise permitted by such regulations. Information
disclosed is potentially subject to re-disclosure by the recipient and no longer protected by the federal code, (45 CFR 164.508 (o)(2)(III)
Information Type :
Written
Scanned
I understand this authorization extends to the release/ of information via U.S. mail, telephone or facsimile machine (fax)..
Purpose of Disclosure:
Continuity of Care
Social Security
Client Request Copies
Financial
Legal
Subpoena
Disposition
Department of Children and Families Benefits
Investigations
Other, please explain:
Information to be disclosed:
Psychiatric/Psychological Evaluation
Comprehensive Assessment
Discharge Summary
Medication Record
Other:
I understand that this authorization is revocable upon written notice to Business Archives except to the extent that action by this agency
has already been taken on this authorization. This authorization shall remain in force for a reasonable time to accomplish the purpose
for which it is given Or will expire in (1) year on this date:
. Unless revoked by written notice and provided said notice is
received prior to the release of the above designated information.
___________________________________
Signature of Client
Date
________________________________________
Signature Witness
/ Date
_______________________________________
Signature of representative (if required) Date
Must be notorized unless dropping off in person with proof of ID.
The foregoing instrument is acknowledge before me on the ____ of ________________, 20___ by: ____________________________
Who is Personally known to me or has/have produced ____________________________________, as identification and did take an
oath.
Witness my signature and official seal in the aforesaid state and county.
Notary Public: ________________________________
Signature/Date
Please make all money orders payable to:
(Seal)
Business Archives, Inc.
413 Oak Pl
Port Orange, FL 32127
Telephone Number: 386-767-7604