2022 Summer Circles Release Of Information

Summer Circles Program - ROI

Cornerstone Academy authorization to release/exchange information with Serenity Behavioral Health Services
I, Name of person authorized to give consent hereby authorize Cornerstone Academy, to release and exchange medical information regarding Name of student Date of birth. Information can be released to and exchanged with Serenity Behavioral Health Services INC.
Dates of treatment: 8/2021 - 6/2022
I authorize the following information to be released:

Narrative SummaryTreatment PlanTermination SummaryDiagnostic AssessmentService DocumentationSchool RecordsProgress NotesIncident ReportsMedical RecordsMental Health Assessments and School Performance
Indicate any exceptions to the information being released:
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
Signature of Client/Guardian*

Clear
Printed Name*
Date*

MonthDayYear
Date
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.
Should be Empty:

Summer Circles Program - ROI