Release of Information

AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION
I voluntarily allow Workit Health to:*

Release my Health InformationReceive my Health Information
Patient Name*

First NameLast Name
Workit Health Clinic:*
Date of Birth*

MonthDayYear
Date
Phone*
Please enter a valid phone number.
Active email address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECTION 1: What information am I agreeing to share?

By signing below, I hereby authorize my Workit Health Clinic or agent, to use or disclose information contained in the medical and financial record of the patient identified above, which includes information that may be stored in a paper and/or other electronic format. Such notes may contain information on general medical care; alcohol and drug abuse treatment; psychological and social work counseling; human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS), or AIDS related complex including communicable diseases or infections, sexually transmitted diseases, venereal diseases, tuberculosis and hepatitis; demographic information; and information from other providers that is contained in the information maintained by my Workit Health Clinic.

Use and Disclosure shall be limited to the following specific information contained in my records and/or obtained during the course of my diagnosis and treatment.
Disclosure of my Health Information is limited to:*

Psychotherapy notesMedical/alcohol/drug abuse evaluation, treatment, referralSexually transmitted diseasesHIV/AIDS-related treatmentMental health records (other than psychotherapy notes)Diagnosis/medication history/medication dosagesDrug Screening ResultsBloodwork/Lab work ResultsPhysical Exam ResultsVerification of TreatmentDates of treatment attendance and treatment plansProgress notes and content of Workit Health coursesDischarge summariesAny information needed for a surgical procedureAny information needed to confirm the validity of my prescriptions and for submission for payment for the prescription
Date range to allow:*

last appointment and prescription onlyprevious 30 daysprevious 90 daysprevious 6 monthsprevious 1 yearfull duration of treatmentOther
SECTION 2: Purpose of disclosure*

Care coordination or treatmentOrdering lab/drug testsRequesting External Physical Exam and or Lab ResultsTo allow Workit Health to access external InformationLegal matterPersonalEmergency ContactAssuring a pharmacy of the validity of any prescription and/or for payment purposesPayment purposes in generalOther (please specify)
SECTION 3: Who do I want to share or disclose my information with?*

To the Patient at the above addressTo another person or organization
Authorized Personel Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Email (if applicable)
example@example.com
Fax Number (if applicable)
Please enter a valid phone number.
SECTION 4: Miscellaneous
- If I fail to specify an expiration date or condition, this authorization is valid for the period of time lasting until I am discharged from my Workit Health Clinic or for up to one (1) year from the signature date, whichever is earlier.
- This authorization is subject to revocation at any time except to the extent my Workit Health Clinic who is to make the disclosure has already acted in reliance on it. Any revocation will be presented in writing to my Workit Health Clinic.
- My Workit Health Clinic will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I provide this authorization.
- I understand that I am explicitly authorizing both the disclosure of my Workit Health Clinic records and the re-disclosure of the other providers records.
- This authorization provides for a release of information about an individual whose confidentiality is protected by federal and state laws and regulation, including the Health Insurance Portability and Accountability Act of 1996 (45 C.F.R. §160-164) as well as 42 C.F.R part 2 and 42 U.S.C. §. §290dd-2, and state confidentiality laws. 42 CFR Part 2 (“Part 2”) prohibits unauthorized disclosure of any Part 2 records. No information disclosed from this authorization may be re-disclosed without the specific written consent of the individual about whom such information pertains.
SECTION 5: Signature

By signing below I acknowledge that I am aware of the confidential and/or privileged nature of the information being disclosed, and understand the benefits and/or disadvantages of disclosing such information. I hereby release my Workit Health Clinic, its affiliates and its agent and representatives, from all legal liabilities that may result from the release of this information according to this request.
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I agree to Workit Health's Terms of Service and Privacy Policy and authorize Workit Health to contact me via email and physical mail.
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AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION