General Release
By signing below, I, the individual named in section “A”, authorize SaVida Health to release my protected health information (PHI) to and/or obtain my
protected health information (PHI) from 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.
The Information authorized to be RELEASED TO and OBTAINED FROM: CHECK ALL THAT APPLY
Effective Dates: One year from the date signed - unless
revoked by you in writing or specified to the right.
Event/condition permission will expire: Treatment completion/termination.
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.