WP E-Signature by Approve Me - Sign Documents Using WordPress -

Elite Recovery, LLC • (612) 719-4137

1137 Grand Ave. Saint Paul, MN 55105  •  840 Grand Ave. Saint Paul, MN 55105  •  937 Grand Ave  Saint Paul, MN 55105  •  1330 Grand Ave  Saint Paul, MN 55105

AUTHORIZATION FOR RELEASE OF PRIVATE HEALTH INFORMATION

A copy of this will be considered as valid as the original

Client Name:
Client Date of Birth:

I, , born on , authorize Elite Recovery, LLC to

The individual and/or agency indicated below:

The following private health information:

Reason(s) for releasing information:

I authorize this information to be shared in the following formats:

I understand that by signing this form, I am requesting that the health information specified above be sent/shared with the third party named above.

This authorization will expire one year from the date signed below unless I specify an earlier date here:

I may revoke/stop this authorization at any time by writing to Elite Recovery, LLC, and understand that such revocation will not have any effect on information released prior to the date of receipt of my notification of revocation.

This information has been disclosed to you from records protected by Federal confidentiality rules (42 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 drug abuse patient. I understand that Elite Recovery, LLC cannot prevent the re-disclosure of records released as a result of this request and that the records may not be subject to privacy rule protections; therefore Elite Recovery, LLC is released from any and all liability resulting from re-disclosure.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

August 31, 2021 4:09 pm CST

ROI Signature Requested by Kara from Elite Recovery Uploaded by Justin Scharr - files@eliterecoverymn.com IP 63.226.140.210

August 31, 2021 4:15 pm CST

Kara Frahm - kara@eliterecoverymn.com added by Justin Scharr - justin@eliterecoverymn.com as a CC'd Recipient Ip: 66.41.72.89

August 31, 2021 4:15 pm CST