Medical Record Release Form - Hazelden Betty Ford Foundation

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First found May 22, 2018

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Authorization to Disclose Medical Records
Patient Name (print):____________________________________________________________ Birthdate: _________________
Other names used in treatment: ________________________________________________ Phone: ______________________
Preferred Method of Release:
___ Mail
___ Fax
___ Flash drive (may take up to 30 days)
Specify the Facility:
___ Rancho Mirage (BFC) or L.A. Outpatient
___ Beaverton
___ Springbrook
___ All other Hazelden Sites/Locations
-CONFIDENTIAL-
___ Email
Approximate date of your treatment (if known): _______________________________________________________________
I authorize the Hazelden Betty Ford Foundation and Recovery Partners to communicate with and release
information to:
Name: _________________________________________________________
Attention: ___________________
Address: _______________________________________________________
Phone: ______________________
______________________________________________________ Fax: _________________________
Email Address – Print Clearly: ___________________________________________
Why the information is needed:
___ Personal
___ Insurance
___ Legal
___ Verify Attendance ___ Treatment/Continuing Care
___ Disability/FMLA
___ Back to Work
___ Other (specify):_______________________________________
Check all types of information to be disclosed to above party (copy fee may apply):
** A Health Information staff member will contact you if a fee is required before records are sent. **
___ Medical/Nursing
___ Face sheet/Insurance Information
___ Labs/X-Rays
___ Letter with Treatment Dates, also include if marked:
___ Medications
Discharge Status
Recommendations/Plan
___ Mental Health
___ Records needed for Insurance Appeal
___ Chemical Dependency
___ Records needed for Disability/FMLA
___ Discharge Summaries/Notes
___ Complete Medical Record (Prepayment Required)
___ Treatment Plan
___ Other:_______________________________________
___ Progress Notes/Continuing Care
_______________________________________
Information and records requested may include reference to my HIV/AIDS status: ___ I do NOT want this included
-CONFIDENTIAL-
I understand that:
• My health information is protected by federal regulations (Alcohol and 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 Hazelden Betty Ford
Foundation (HBFF)’s Privacy Notice.
• I understand that I have a right to inspect and receive a copy of my treatment records that may be disclosed to others, as provided under
applicable state and federal laws.
• I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. HBFF’s Privacy Notice outlines the
procedure for revocation. This authorization will expire in one year from the date I sign it unless I request an earlier expiration.
• For disclosures other than for treatment, payment and health care operations purposes, treatment may not be conditioned on my
agreement to sign an authorization (unless I am receiving care solely to create protected health information for disclosure to a third
party [42 CFR § 164.508(b)(4)(iii)].
• Communications resulting from this authorization will reveal that I received services at HBFF.
• Federal confidentiality regulations (42 CFR Part 2) prohibit redisclosure of information from alcohol and drug abuse patient records.
However, HIPAA requires HBFF to notify me of the potential that information disclosed pursuant to this authorization might be redisclosed
by the recipient and is no longer protected by the HIPAA rules.
• This authorization may be used by HBFF owned or managed programs upon transfer of my care to them.
Patient Signature: ___________________________________________________________Date: __________
Parent/Guardian Signature: _______________________________________________________________ Date: ___________
(when required)
Betty Ford Center/L.A.
Health Information Department
39000 Bob Hope Drive
Rancho Mirage, CA 92270
Fax: 760-773-4180
Location Information:
Hazelden Beaverton
Health Information Department
6600 SW 105th Ave, Suite 120
Beaverton, OR 97006
Fax: 503-641-5179
Hazelden Springbrook
Health Information Department
1901 Esther Street
Newberg, OR 97132
Fax: 503-537-7007
Hazelden (all other locations)
Health Information Department
15251 Pleasant Valley Rd
PO Box 11, BC 22
Center City, MN 55012-0011
Fax: 651-213-4496
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