2024 Release of Information Form

Serenity Behavioral Health Services Authorization to Release/Exchange Information
NOTE: If the client is 18 years of age or older, the client is the only person permitted to complete and sign this form. If the client is under the age of 18, the parent or guardian must complete and sign this form.
I do hereby consent and authorize Serenity Behavioral Health Services to release and exchange information contained in my medical records. *
Please state your relationship to the client:*

SelfLegal parentGuardianOther
Records are to be disclosed to and/or exchanged from:*
My current therapist or prescriber is:
Select how you would like for your information to be exchanged:*

Mailed to above addressEmailed to above email addressVerbal/phone conversationsURGENT: please FAX to the above fax number
Please authorize (select) the information you would like exchanged/shared:

Narrative SummaryDiagnostic AssessmentProgress NotesService DocumentationService Plan (ISP)Discharge SummaryIncident ReportsSchool/Employment RecordsMedical Orders/RecordsLab OrdersIndicate any exceptions to the information being released: (select to specify)
Amount of information to be disclosed:

Past 3 monthsCovering most recent admissionOther
Purpose of information disclosure :

Continuity of careReferralOther
I UNDERSTAND (please read and select all):*

I may revoke this Authorization at any time. The revocation will not apply to the information that has already been released in response to this Authorization. I must revoke this Authorization in writing. The procedure for revoking this Authorization is to present/send my written revocation to 623 Park Meadow Road, Suite H, Westerville, OH 43081, Attn: Medical Records CoordinatorI may refuse to sign this Authorization. My treatment, payment, enrollment in a health plan or eligibility for benefits cannot be conditioned upon my authorization of this disclosure. A fee may be charged for copying your protected health information.I have been informed and understand the information disclosed pursuant to this Authorization may be subject to re-disclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no longer be protected under federal medical privacy law.
Unless otherwise revoked, this authorization will expire:*

At the termination of my treatment60 days from today's authorizationOn the following event or condition: (select to specify)
Signature of Client/Guardian/Personal Rep*

Clear
Printed Name*
Date

MonthDayYear
Date
Witness
Date

MonthDayYear
Date
Printed Name
If this authorization has been signed by a personal representative on behalf of an individual, his/her authority to act on behalf of the individual must be set forth here:
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.
For Office Use Only
Staff Releasing Information
Date Released

MonthDayYear
Date information was released
I hereby revoke my permission for use of disclosure of my protected health information to the party specified above. Further release of information shall cease immediately.
Client Signature

Clear
Today's Date

MonthDayYear
Date
Signature of Staff Witness

Clear
Date

MonthDayYear
Date
Should be Empty:

Serenity Behavioral Health Services Authorization to Release/Exchange Information