"Bridges of Iowa Consent to Release of Information" - Iowa

Bridges of Iowa Consent to Release of Information is a legal document that was released by the Iowa Department of Corrections - a government authority operating within Iowa.

Form Details:

  • Released on May 1, 2020;
  • The latest edition currently provided by the Iowa Department of Corrections;
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Consent to Release of Information
1
I ____________________________________ (​ P rinted Client Name ​ ) , direct ​ B ridges of Iowa​ to disclose my
2
HIPAA and 42 CFR part 2 protected health information to:
Name (agency or entity ​ a nd​ a specific physician or person)
Address/Phone
Bridges of Iowa​ may disclose the following (​ i nitial all that apply ​ ) :
_____ **​ A ll protected information​ * *
_____ Laboratory results
or Individually:
_____ Legal history
_____ Alcohol and drug history
_____ Medical history
_____ Assessments and test
_____ Physical examination
X
(Before 2014 or After 6-15-17)
_____ Attendance records
_____ Program status
_____ Billing records
_____ Progress notes
_____ Coordination of care
_____ Social history
_____ Discharge summary
_____ Summary of treatment
_____ Evaluations
_____ Treatment plans
X
_____ Financial and insurance information
_____ Other (please specify):
Please
provide breakdown of dates for the 3.5, 3.1,
_____ Initial evaluation and recommendation
and 2.5 levels of care.
By signing this form I understand and agree that I may revoke my consent at any time, except to the extent that
Bridges of Iowa has already disclosed information in reliance on this form. I have been provided a copy of this
form, as well as the notice prohibiting redisclosure of my records that will be provided to anyone receiving my
records pursuant to this release.
--- Consent to Release ---
--- Revocation ---
Client Signature
Date
Client Signature
Date
Staff Signature (witness)
Date
Staff Signature (witness)
Date
1
NOTICE PROHIBITING RE-DISCLOSURE OF SUBSTANCE USE DISORDER INFORMATION This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR
part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies the person identified in these records as a guest of Bridges of Iowa, or as having or
having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly
permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is
NOT sufficient for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as
provided at §§ 2.12(c)(5) and 2.65.
2
Alcohol and drug treatment records are protected both under the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, and the Confidentiality of Alcohol And Drug Abuse
Patient Records, 42 CFR Part 2. Unless otherwise provided for in the regulations, these types of records cannot be released without the specific written consent of the guest. This release will
automatically expire one year from the date on which a guest is discharged from the program. Any information released pursuant to this release may not be re-disclosed without the consent of the guest.
Created 05.21.18
May 2020
AD-CR-02 F-11
Consent to Release of Information
1
I ____________________________________ (​ P rinted Client Name ​ ) , direct ​ B ridges of Iowa​ to disclose my
2
HIPAA and 42 CFR part 2 protected health information to:
Name (agency or entity ​ a nd​ a specific physician or person)
Address/Phone
Bridges of Iowa​ may disclose the following (​ i nitial all that apply ​ ) :
_____ **​ A ll protected information​ * *
_____ Laboratory results
or Individually:
_____ Legal history
_____ Alcohol and drug history
_____ Medical history
_____ Assessments and test
_____ Physical examination
X
(Before 2014 or After 6-15-17)
_____ Attendance records
_____ Program status
_____ Billing records
_____ Progress notes
_____ Coordination of care
_____ Social history
_____ Discharge summary
_____ Summary of treatment
_____ Evaluations
_____ Treatment plans
X
_____ Financial and insurance information
_____ Other (please specify):
Please
provide breakdown of dates for the 3.5, 3.1,
_____ Initial evaluation and recommendation
and 2.5 levels of care.
By signing this form I understand and agree that I may revoke my consent at any time, except to the extent that
Bridges of Iowa has already disclosed information in reliance on this form. I have been provided a copy of this
form, as well as the notice prohibiting redisclosure of my records that will be provided to anyone receiving my
records pursuant to this release.
--- Consent to Release ---
--- Revocation ---
Client Signature
Date
Client Signature
Date
Staff Signature (witness)
Date
Staff Signature (witness)
Date
1
NOTICE PROHIBITING RE-DISCLOSURE OF SUBSTANCE USE DISORDER INFORMATION This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR
part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies the person identified in these records as a guest of Bridges of Iowa, or as having or
having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly
permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is
NOT sufficient for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as
provided at §§ 2.12(c)(5) and 2.65.
2
Alcohol and drug treatment records are protected both under the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, and the Confidentiality of Alcohol And Drug Abuse
Patient Records, 42 CFR Part 2. Unless otherwise provided for in the regulations, these types of records cannot be released without the specific written consent of the guest. This release will
automatically expire one year from the date on which a guest is discharged from the program. Any information released pursuant to this release may not be re-disclosed without the consent of the guest.
Created 05.21.18
May 2020
AD-CR-02 F-11