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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