Release of Information Form

We cannot discuss your program, progress or health information with anyone---not even your spouse or loved ones---without written permission. 

Submit the form below to tell us with whom and what we can share.  Think ahead to your treatment and submit as many times as you need.  For instance, Spouse, Loved One, Doctors, Attorney, Parole Officer or person paying for your treatment should each be submitted separately. 

If you need reports sent, please use the Request a Report Form instead of this form.

Release of Information

* Your Name

* Last 4 digits of your SS#

* Who may we share your health information with: (People or Organization)

 * Select the types of information that we may share:
General summary of my progress (program, attendance and abstinence)

Financial and Insurance Information

Detailed Clinical Records

Other Describe

* I have read and understand the full terms (Click to Read Now) of this release of information which include (1) Authorization for my insurance company to re-disclose my information, (2) My records are protected and cannot be disclosed without written consent and (3) I may revoke this consent at any time in writing.

* Signature