Authorization to Disclose Health Information

Are you requesting to receive a copy of your own records as a client of Northpoint, or are you requesting that a copy of your records be sent to another person or entity?

I am requesting to receive a copy of my own records

I am requesting that a copy of my records to be sent to another person or entity

Name of patient requesting disclosure of medical records(Required)

First Last

Name at Time of Treatment (if different than above):

Patient Date of Birth(Required)

Last 4 digits of SSN(Required)

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I am requesting records for:(Required)

Which facility are you requesting records from?(Required)

Northpoint Recovery (Meridian, ID)

Northpoint Washington (Edmonds, WA)

Northpoint Colorado (Loveland, CO)

Northpoint Nebraska (Omaha, NE)

Which facility are you requesting records from?(Required)

Ashwood Recovery (Boise, ID)

Northpoint Seattle (Seattle, WA)

Northpoint Loveland (Loveland, CO)

Northpoint Omaha (Omaha, NE)

Northpoint Lincoln (Lincoln, NE)

Northpoint Westminster (Westminster, CO)

Information to be disclosed in release of records (please check all that apply)(Required)

Message:

I would like my records sent via:(Required)

Address you would like records sent:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Fax number where you would like records sent:(Required)

mail address where you would like records sent:(Required)

Name of patient requesting disclosure of medical records(Required)

First Last

Email address of patient requesting disclosure of medical records(Required)

Patient Date of Birth(Required)

Last 4 digits of SSN(Required)

I am requesting records for:(Required)

Which facility are you requesting records from?(Required)

Northpoint Recovery (Meridian, ID)

Northpoint Washington (Edmonds, WA)

Northpoint Colorado (Loveland, CO)

Northpoint Nebraska (Omaha, NE)

Which facility are you requesting records from?(Required)

Ashwood Recovery (Boise, ID)

Northpoint Seattle (Seattle, WA)

Northpoint Loveland (Loveland, CO)

Northpoint Omaha (Omaha, NE)

Name of person or organization you would like to send records to(Required)

I would like my records sent via:(Required)

Address of the organization/person you would like records sent:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Fax number of organization/person you would like records sent:(Required)

Email address or organization/person you would like records sent:(Required)

Phone number of organization/person to receive medical records(Required)

Information to be disclosed in release of records (please check all that apply)(Required)

Message:

Purpose for the disclosure of medical records (please check all that apply)(Required)

Treatment/Continuing medical care

Personal use

Billing or claims

Insurance

Legal purposes

Disability determination

School

Employment

Other (please specify in notes)

Message:

Additional Information(Required)

By signing below, you certify your understanding that your medical records to be disclosed under this Authorization are protected under Federal Confidentiality regulations (42 CFR Part 2}. Published August 10. 1987, and the Heath Insurance Portability and Accountability Act of 1996 (P.L. 104-191 ), 42 U.S.C. Section 1320d, et. Seq, and cannot be disclosed without your written consent unless otherwise provided for in the regulations.

Unless sooner revoked, this Authorization expires in 12 months or upon termination of your treatment at Northpoint Recovery, whichever is later; provided that the Authorization shall expire in 12 months to the extent it authorizes disclosure of medical records to a financial institution or to my employer for purposes other than payment.

By signing below, you certify your understanding that you might be denied services if you refuse to authorize disclosure of your medical records for purposes of treatment, payment, or health care operations, if permitted by state law. You will not be denied services if you refuse to authorize the disclosure of your medical records for other purposes.

Unless you have requested in writing that disclosure be made in a certain format, we reserve the right to disclose medical records as permitted by this Authorization in any manner we deem to be appropriate and consistent with applicable law, including but not limited to verbally, in paper format, or electronically.

You understand that medical records used or disclosed pursuant to this Authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Each disclosure of medical records subject to 42 CFR Part 2 made by Northpoint with your written consent will be accompanied by the following statement: “42 CFR Part 2 prohibits unauthorized disclosure of these records.”

You understand that you have a right to revoke this Authorization, in writing, at any time by sending written notification to medicalrecords@northpointrecovery.com. You further understand that a revocation of the Authorization is not effective to the extent that action has been taken in reliance on this Authorization. You may request a copy of this Authorization for your records by emailing medicalrecords@northpointrecovery.com.

Check here to indicate that you have read and agree to the terms of this Authorization.

By submitting this form, I agree to receive communications, including texts, calls, and/or emails, regarding services, appointments, alumni resources, and news from Northpoint brands.