Release of Information

(In case of questions)

*THIS FORM IS NOT A RECORD REQUEST. PLEASE CONTACT OUR OFFICE TO REQUEST RECORDS. THIS FORM ONLY GIVES US PERMISSION TO DO SO ONCE REQUESTED.* Contact information can be found on our website. I understand by signing this form I am allowing Hope Springs Behavioral Consultants to release/obtain medical information concerning the above-named patient to/from:

Please provide accurate contact information for method chosen. If records are inadvertently received by an unauthorized recipient, through no fault of the sender, I waive claim against the sender.

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.
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