Release of Information

A release of Information is REQUIRED for Sandhills Best Care to communicate with your other providers / School counselors / and to get your records from past or current providers. Additionally, if you wish us to send your information to a different provider, we must have on file a "Release of Information".

Release of Information

Authorization for Use and Disclosure of Protected Health Information This authorization form implements the requirements for client authorization to use and disclose health information protected by the federal health privacy law (45 CFR 160, 164), the federal drug and alcohol confidentiality law (42 CFR 2), and the disabilities and substance abuse services (GS 122C).

Sandhills BEST Care

INTERNAL Office Use Only

Client Name: _________________________________

DOB: ________________ Record #: _________________

Staff Witness Signature: _________________________

Date: _________________

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Client or Guardian FULL Name

give Sandhills Best Care, authorization to communicate with, obtain health records from and share health records and information with the following providers and/OR schools:

Provider

Provider Phone Number

Provider Practice Name

Provider Fax Number

School Counselor

School Phone Number

School Name

School Fax Number

Provide your name or family member info who will be a client.

Client First Name

Client Last Name

Client Birthday

Client Address

Phone Number

Social Security Number

Grade In School or NA

Guardian Name (if minor)

Guardian Relationship to Minor

NOTE: If a minor has been displaced, under the care of DSS or a court ordered custody situation has been established, please upload guardianship paperwork with this referral. You may submit this after the fact, but before care can be established.

Guardianship Paperwork

Upload File

Primary Insurance Name

Primary Insurance Number

Secondary Insurance Name

Secondary Insurance Number

Purpose of this Disclosure (check all that apply)

Any other Information to Disclose

Redisclosure Once information is disclosed pursuant to this signed authorization, I understand that the federal privacy law (45 CFR 160, 164) protecting health information may not apply to the recipient of the information and therefore may not prohibit the recipient from disclosing it. Other laws, however, may prohibit disclosure. When we disclose mental health and developmental disabilities information protected by state law (GS 122) or substance abuse treatment information protected by federal law (42 DFR 2), we must inform the recipient of the information that disclosure is prohibited except as permitted or requested by these two laws.

Revocation and Expiration I understand that with certain exceptions, I have the right to revoke this authorization at any time. The procedure of how I may revoke this authorization, as well as the exceptions to my right to revoke, have been explained to me. If not revoked earlier, this consent shall be valid for one year from the date signed unless otherwise indicated below:

Date of expiration, if less than one year

Event, if less than one year for revocation.

Any other information you would like for us to know?

Notice of Voluntariness I understand that I may refuse to sign this authorization form.

Client Signature

Select a date

Guardian Signature (if minor)

Select a date

Mobile Phone Disclaimer: By clicking the box, I agree and acknowledge that Sandhills Best Care may send text messages to my wireless phone number for business-related purposes. Message and data rates may apply. Message frequency will vary and I will be able to opt-out by replying “STOP”. For more information on how my data will be handled, click here in order to review the PRIVACY POLICY.

Release of Information