Release of Information

This form is used to release your protected health information as required by federal and state privacy laws.

If you are human, leave this field blank.

Client First Name *

Client Last Name *

Client Date of Birth *

Social Security Number *

I hereby authorize Mesa Vista Wellness to: *

Release to

Obtain information from

Release to and obtain information from

Name of person or business to release to or obtain from *

Address *

City, State, Zip Code *

Phone Number *

Fax Number

PERSONS ACQUIRING INFORMATION FOR REASONS OTHER THAN CLIENT TREATMENT PURPOSES ARE WARNED THAT THE INFORMATION IS COVERED BY FEDERAL REGULATIONS RESTRICTING RE- DISCLOSURE WITHOUT FURTHER AUTHORIZATION FROM THE CLIENT. MESA VISTA WELLNESS WILL NOT RELEASE DOCUMENTS RECEIVED THROUGH RELEASE FROM OTHER AGENCIES WHICH ARE CONTAINED IN MESA VISTA WELLNESS’ CLIENT FILE.

Information being requested may be released: *

Verbally

Written

Verbally and written

I authorize release of the following specific information from the stated time period: *

Previous 12 months

Previous 6 months

Entire treatment history

Other - from (specify start and end dates):Other - from (specify start and end dates):

I understand that if I have had treatment for drug and alcohol abuse my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Client Records and cannot be disclosed without my written consent and otherwise provided for in the regulations. I also understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance on it. This consent shall expire one year from date of signature, or when discharged, unless otherwise instructed in writing by the client or legal guardian.

Signature of Client (if client is over 14 yrs and drug or alcohol treatment is involved) *

Clear

Signature of Legal Guardian (for minor children)

Clear

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Release of Information

Mesa Vista Wellness Consent for Release of Information

CAREERS

THE DANA FUND

HEALING EVENTS

CEUs

LOCATIONS

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Release of Information

Mesa Vista Wellness Consent for Release of Information

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