Release of Information to FESC - Forensic Evaluation Service Center

CONSENT FOR RELEASE OF PART 2 PROGRAM INFORMATION & MENTAL HEALTH TREATMENT RECORDS

Fields marked with an asterisk are required to completed or the form cannot be submitted.

This form is not a patient access request, under 45 CFR 164.524.

Records released pursuant to this authorization may include information concerning testing, diagnosis or treatment of HIV/AIDS, psychiatric and/or drug/alcohol treatment, and our/or sexual assault.

Your Full Name as it would appear on your medical records *

First

Last

Your date of birth - MM/DD/YYYY *

06/11/1996

Name of the agency or doctor to who you are giving permission to release the records *

Substance abuse treatment provider, a mental health provider or hospital or DOCTOR that you have seen.

I hereby authorize the disclosure of health information about the above named individual to FESC Legal Examiner.

I authorize the release of the records from the healthcare provider listed above to these Non-Treatment Providers: *

FESC: 1244 Nilles Road, Suite #9, Fairfield, OH 45014 email: forensicservices@fesc-oh.org

Fax 30 pages or less to 513-867-5868

The reason for Releasing these records is: *

Court-ordered Evaluation

The information being requested are: (1) history & discharge summary, (2) diagnoses, and all mental health and (3) substance use assessment information. *

I agree

Release information from these years: *

1/1/2020 to currently

This authorization will be revoked one year from the date of signature *

I agree

This release will remain in effect until revoked or shall expire on date specified above, or at any time I submit in writing a revocation of the release.

I understand that information disclosed by this authorization cannot be redisclosed without my written consent or unless otherwise provided for in the regulations. *

I understand

HIPAA - Health Insurance Portability and Accountability Act

I understand that I may not be denied treatment, payment, and enrollment in the health plan, or eligibility for benefits for refusing to authorize disclosure unless such denial is permitted under state and federal law. *

I understand

HIPAA - Health Insurance Portability and Accountability Act

Your Signature *

Use your mouse to sign this document.

Date of signature

for instance 07/04/1776

Your Email Address

This will be used for your receipt of this form.