Release of Information

I authorize Hope Springs Behavioral Consultants to disclose information to and/or obtain information from the below person and/or place. This authorization will be valid for one (1) year from the date of submission.

*Check all that apply. We will only be allowed to share information that you select.

Unless you have specifically requested in writing that the disclosure be made in a certain format only, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to: verbally, in paper format, or electronically.

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. This form does not authorize re-disclosure of medical information beyond the limits of the consent.
I understand that I may review the disclosed information or ask questions by contacting the office. I may be charged for copies in accordance with state law.

I understand the information to be disclosed 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 Hope Springs Behavioral Consultants, 1303 5th Street, Suite 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.

This agreement will expire one year from the date of signature, unless previously revoked or otherwise indicated.

I understand that Hope Springs Behavioral Consultants does 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 for review of a third party, refusal to sign may result in a denial of those services.

ATTENTION: This is a legal document. By signing, I agree to, understand, and accept the terms of this authorization. If records are inadvertently received by an unauthorized recipient, through no fault of the sender, I waive claim against the sender.

If the client is 18 years of age or older, the client must sign and date this form.
If the client is 18 years of age or older and incapable of signing, a legally authorized substitute may sign and date this form.
If the client is 17 years of age or younger, the client's parent or legal guardian must sign and date this form, unless an exception exists under state of federal law.

Print Friendly, PDF & Email