Streamlined Release of Information

Patient Name*

First NameLast Name

Date of birth*

Date

Phone*

Please enter a valid phone number.

Active email address*

example@example.com

Which contact method do you prefer?*

PhoneEmail

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; substance use disorder 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 are contained in the information maintained by my Workit Health Clinic.

The boxes I check below allow Workit Health Clinic to share information from that category:*

Substance Use Disorder Treatment RecordsRecords regarding Mental Health and Developmental DisabilitiesHIV-related test results and treatment informationOther: Please specify …

Date range to allow:*

All timeLast appointment and prescription onlyOther: Please specify …

SECTION 2: Purpose of disclosure*

At the request of the member

SECTION 3: Who do I want to share or disclose my information with?

Name of recipient (person or organization)*

Which communication method should Workit Health use with your recipient?*

EmailFax

Phone*

Please enter a valid phone number.

Recipient's Email

example@example.com

Recipient's Fax Number

Please enter a valid phone number.

SECTION 4: Miscellaneous

The records used or disclosed pursuant to this authorization could be re-disclosed by the recipient. In this case, the records would no longer be protected by the substance use disorder patient records confidentiality law located at 42 CFR Part 2.

The patient's record (or information contained in the record) may be redisclosed in accordance with the permissions contained in the HIPAA regulations, except for uses and disclosures for civil, criminal, administrative, and legislative proceedings against the patient.

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..

Date of last attended appointment

Date

Signature

Today's date

Date

I agree to receive text and email messages and may opt out at any time. View Workit Health's Privacy Policy, Terms of Service, and Consent to SMS and Email.

AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION