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 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.
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.
ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form. This agreement will expire one year from the date of signature, unless previously revoked or otherwise indicated.
- 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.