EMERGENCY CONTACT
By signing below, I, the individual named in section “A”, authorize SaVida Health to release my protected health information (PHI) to the individual
and/or agency named in section “B” as specified below. Furthermore, I understand that my alcohol and/or drug treatment records are protected under
the Federal Regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the
regulations. I understand that my treatment or payment for my treatment cannot be conditioned on the signing of this authorization. I also understand
that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires
automatically.
Savida Health has permission to contact the person in section B on my behalf in the event of an emergency:
Effective Dates: One year from the date
signed - unless revoked by you in writing or
specified to the right.
The purpose of releasing or obtaining this information is:
This notice accompanies a disclosure of information concerning a patient in alcohol/substance use disorder treatment, made to you with the consent
of such patient. This information has been disclosed to you from records protected by federal confidentiality rules, 42 Code of Federal Regulations
(CFR), Part 2. The federal rules 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 the information to criminally investigate or prosecute any
alcohol or substance use disorder patient.