Dates of treatment: 8/2021 - 6/2022

I authorize the following information to be released:

• Narrative Summary
• Treatment Plan
• Termination Summary
• Diagnostic Assessment
• Service Documentation
• School Records
• Progress Notes
• Incident Reports
• Medical Records
• Mental Health Assessments & School Preformance

Amount of information to be disclosed: Student information from 8/2021 - 6/2022

Purpose of disclosure of information: To identify students struggling with mental or behavioral health issues. Provide therapeutic support and counseling services to students and their families.

This authorization will expire upon the completion of treatment.

I understand I have the right to shorten the authorization period. I understand that I have the right to revoke this authorization at any time in writing, and that the revocation will be effective from that date forward. My written statement that I want to revoke my authorization should be delivered to:

 

Serenity-BHS, 623-H Park Meadow Road, Westerville, Ohio 43081

Or Email: mkwright@serenity-bhs.org

Note: This information has been disclosed to you from records whose confidentiality is protected from disclosure by State and Federal law. ORC 5 I 22.31, 45 CFR Part 2, and/or ORC 3701 .243 prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 CF Parts 160 and I 64. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.