I(Required)
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authorize Ashley Addiction Treatment to release and/or receive information regarding my protected health information as directed herein to:
INCLUDE EACH: Name/Entity (who will receive the information; use one form for each individual/entity), address, phone, FAX, & email address. Please Note: Incomplete contact information will result in the inability to fulfill your request.(Required)
Purpose of the Disclosure (describe the reason for the disclosure; please be as specific as possible)(Required)
Information to be released (should be as limited as possible)(Required) The confidentiality of substance use disorder patient records and information created by Ashley Addiction Treatment (“Ashley”) is protected by federal law and regulations (42 U.S.C. 290dd-3, 42 U.S.C. 290ee-3, and 42 CFR Part 2). Generally, Ashley may not disclose to a third party that a patient participates in any inpatient or outpatient substance use disorder treatment program nor disclose any information identifying an individual as having or having had a substance use disorder. Ashley is only permitted to disclose substance use disorder
information without patient consent in limited circumstances (e.g., reporting certain crimes and child abuse, in medical emergencies, for audits and evaluations, and in response to subpoenas or pursuant to a court order).
Violation of the federal law and regulations protecting substance use disorder information by Ashley is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the program, against any person who works for the program or about any threat to commit such a crime. In addition, federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.
I understand that my records are protected under federal confidentiality regulations (42 CFR Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions. I also understand that I may revoke this authorization at any time upon written notice to Ashley. I acknowledge that such revocation will not be effective if Ashley has already acted in reliance upon this authorization. This authorization expires after one (1) year of the date of signature if not previously revoked. I understand this communication will reveal my presence as a patient at a treatment facility.
Prohibition on re-disclosure: This information has been disclosed from records protected by federal confidentiality rules (42 CFR Part 2). These rules prohibit making any further disclosure of this information unless further disclosure is explicitly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. These rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
By signing below, I authorize, consent to, and instruct Ashley Addiction Treatment to use, disclose, and release my health information as described above. I also acknowledge, agree and understand the following:
• Right to revoke: Except to the extent action has already been taken in reliance on this consent and authorization, I can, at any time, revoke (take back) this consent and authorization by submitting a notice in writing to Ashley Addiction Treatment, Health Information Management, 800 Tydings Lane, Havre de Grace, MD, 21078.
• Expiration date: This consent and authorization will expire one (1) year from the date it is signed.
• Re-disclosure: Some information used or disclosed pursuant to this consent and authorization could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.
• Not required: I do not have to sign this consent and authorization, and Ashley Addiction Treatment will not condition my treatment, payment, enrollment or eligibility for benefits if I do not sign this consent and authorization.
• Electronic disclosures: Disclosures of my information pursuant to this consent and authorization may occur via electronic means.
I have read this consent and authorization, and I confirm that it is consistent with my directions. I understand that by signing this form, I am authorizing the use and disclosure of confidential health information. I understand that this consent and authorization is voluntary, that the information to be used and disclosed is protected by law, and that the uses and disclosures are to be made to conform to my directions.
By typing my name below, I acknowledge that I am signing this document electronically. I acknowledge, understand, and agree that signing this document using this electronic signature will have the same legally binding effect as signing my signature using pen and paper. In addition, by clicking the box, I agree the signature I have indicated above will be the electronic representation of my signature for use on the following document.
If you are not the patient but are signing on behalf of the patient, please complete the following and provide supporting documentation.
confirm that I am the legal representative of the patient identified above
By typing my name below, I acknowledge that I am signing this document electronically. I acknowledge, understand, and agree that signing this document using this electronic signature will have the same legally binding effect as signing my signature using pen and paper. In addition, by clicking the box, I agree the signature I have indicated above will be the electronic representation of my signature for use on the following document.
Representative's Signature 
