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Authorization to Release or Request Information
Jewish Family and Career Services of Atlanta
4549 Chamblee Dunwoody Road
Phone 770.677.9389
Fax 770.677.9400
Client Information
First Name:
*
Last Name:
*
Date of Birth:
*
Birth Sex:
*
Address:
City:
State:
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Zip Code :
Phone No:
I hereby authorize Jewish Family & Career Services to:
Release to:
Request from:
Name, Address Phone
Enter Name, Address, Phone and Fax
Name:
Address:
Address Line 2:
City:
State:
Select A State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Alberta, Canada
British Columbia, Canada
Manitoba, Canada
New Brunswick, Canada
Newfoundland / Labrador, Canada
Northwest Territories, Canada
Nova Scotia, Canada
Nunavut, Canada
Ontario, Canada
Prince Edward Island, Canada
Quebec, Canada
Saskatchewan, Canada
Yukon, Canada
Australian Capital Territory, Australia
Jervis Bay Territory, Australia
New South Wales, Australia
Northern Territory, Australia
Queensland, Australia
South Australia, Australia
Tasmania, Australia
Victoria, Australia
Western Australia, Australia
Guanacaste, Costa Rica
Alajuela, Costa Rica
Heredia, Costa Rica
San Jose, Costa Rica
Cartago, Costa Rica
Limon, Costa Rica
Puntarenas, Costa Rica
Zip Code:
Phone:
(Business)
(Cell)
Fax:
Email:
Check appropriate documents to be released or requested:
Initial Clinical Assessment
Social History
Diagnosis
Telephone Reports/Verbal Communications
Treatment Plan
Consultations
Progress Summaries
Closing Summary/Recommendations
Psychological Evaluation
Psychiatric Evaluation
Compliance with Treatment
Written Correspondence
Other, please specify:
Ongoing service provided by a cooperating service provider
I authorize the following named individual, an employee and/or designee of Jewish Family & Career Services, Inc.:
To release information to or to receive information from the above listed organization and/or individual, for the purpose of:
This authorization is valid for ninety (90) days from the date of my signature. However, if “ongoing service” is checked, authorization is valid for one calendar year. “On-going service” applies to current services received at JFCS concurrent with services provided by another service provider.
Conditions
I further understand that JFCS will not condition my treatment on whether I give authorization for the requested disclosure.
Insert an explanation of the consequences, if any, of not signing this authorization, which will depend on the services being provided.
I understand I may revoke this authorization at any time by submitting a written request to the attention of the JFCS Privacy Officer. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
Form of Disclosure
Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
Redisclosure
Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2.
Other types of information may be re- disclosed by the recipient of the information in the following circumstances:
Furthermore, I hereby release Jewish Family & Career Services and its employees from any and all liabilities, responsibilities, damages and claims which might arise from the release of the information authorized above. I understand the records released may contain sensitive materials including alcohol and/or drug information and psychiatric information. I understand that information may be transmitted by electronic means such as by fax and/or e-mail. Portions of the information provided may not pertain exclusively to my current diagnosis.
I will be given a copy of this authorization for my records.
Signature of Patient/Client
Signer Type:
Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
Name:
Sign with Touch
Signature of Parent, Guardian or Personal Representative
If you are signing as a personal representative of an individual, please describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.)
Signer Type:
Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
Name:
Sign with Touch
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