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Flora Essentials Consent Release of Information Form

1. PATIENT INFORMATION

Patient Full Name

2. I AUTHORIZE:

Flora Essentials
1330 Win Hentschel Blvd. Suit 269
West Lafayette, IN 47906
(765) 421-5755

TO:

3. ORGANIZATION/INDIVIDUAL INFORMATION

Address

4. INFORMATION TO BE RELEASED

Checkboxes

OR indicate the specific categories to be released:

Categories

5. PURPOSE FOR DISCLOSURE

Checkboxes

6. I UNDERSTAND THAT:

  • My health information is protected by federal regulation (Alcohol & Drug Abuse Patient Records, 42 CFR Part 2; and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Flora Essentials' Privacy Notice.
  • I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Flora Essentials' Privacy Notice outlines the procedure for revocation. This authorization will expire in one year from the date I sign or unless I request an earlier expiration in writing.
  • For disclosures other than for treatment, payment and healthcare purposes, treatment may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) (45 CFR & 164.508 (b)(4)(III)).
  • Communications resulting from this authorization will reveal that I receive services at Flora Essentials.
  • Federal confidentiality regulations (42 CFR Part 2) prohibit re-disclosure of information from alcohol & drug abuse patient records. However, HIPAA requires Flora Essentials to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA.
  • This authorization may be used by Flora Essentials owned or managed programs upon transfer of my care to them.

7. SIGNATURE

Clear Signature
Clear Signature
Representative's Name