Authorization to Release Information
- By completing this form and clicking "Read and Agree" below, I authorize the source named herein to speak by telephone with Saratoga Center for the Family staff about information that can assist with me/the client receiving treatment or being evaluated or referred elsewhere. I give my permission to release/obtain information from any staff member at the listed agency as necessary to coordinate services.
- I understand that no services will be denied me/the client solely because I refuse to consent to this release of information, and that I am not in any way obligated to release these records. I do release them because I believe that they are necessary to assist in the development of the best possible treatment plan for me/the client. The information disclosed may be used in connection with my/the client’s treatment.
- This request/authorization to release confidential information is being made in compliance with the terms of the Privacy Act of 1974 (Public Law 93-579) and the Freedom of Information Act of 1974 (Public Law 93-502); and pursuant to Federal Rule of Evidence 1158 (Inspection and Copying of Records upon Patient’s Written Authorization). This form is to serve as both a general authorization, and a special authorization to release information under the Drug Abuse Office and Treatment Act of 1972 (Public Law 92-255), the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act Amendments of 1974 (Public Law 93-282), the Veterans Omnibus Health Care Act of 1976 (Public Law 94-581), and the Veterans Benefit and Services Act of 1988 (Public Law 100-322). It is in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191.It is also in compliance with 42 C.F.R. Part 2 (Public Law 93-282), which prohibits further disclosure without the express written consent of the person to whom it pertains, or as otherwise permitted by such regulations.
- In consideration of this consent, I hereby release the source of the records from any and all liability arising therefrom.
- I have been informed of the risks to privacy and limitations on confidentiality of the use of electronic means of information transfer, and I accept these.
- I affirm that everything in this form that was not clear to me has been explained. I also understand that I have the right to receive a copy of this form upon my request.