Consent for Release of Confidential Information

I , SSN #: , DOB: , authorize dba Dresden House, POB1105, Sedalia, MO 65302-1105 to disclose my identifying information, financial information, and continuity of care information to the agency listed below:

The purpose of this disclosure is to assist in the development and coordination of my treatment for an alcohol or drug problem, or mental illness.

I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Client Records, 42 CFR Part 2, and the Health Insurance Portability & Accountability Act of 1996 (HIPAA_) and cannot be disclosed without written request unless otherwise provided for in the regulations.

I also understand that I may revoke this consent at any time but that this revocation would not cover disclosures made while the consent was active. Revocation must be accomplished per written request and may be for specific items or the entire release.

This consent will automatically expire in one (1) year from date of signature unless there is a different specification of date, event, or condition noted below:

I understand that generally Recovery Prison Ministries may not condition my treatment on whether I sign a consent form, but that in certain limited circumstances I may be denied treatment if I do not sign a consent form.

Would you like a copy of this authorization? Please initial: Yes No

If yes, copies will be mailed to you if not provided to you immediately.

Signature of Client Date

Signature of Witness Date

Signature of Parent/Guardian/Legal Representative Date

(Specify relationship to client: ).