Release of Information - Client


Elite Recovery, LLC   •  1137 Grand Ave. Saint Paul, MN 55105   •   (612) 719-4137

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:   
Person Signing Forms is the:   
Name of Person Signing Forms:   

 

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.

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Signature Certificate
Document name: Release of Information - Client
lock iconUnique Document ID: 88d6f3f21796a9abc704b7664c2b1ca5c8b0c939
Timestamp Audit
December 16, 2020 8:14 am CSTRelease of Information - Client Uploaded by Justin Scharr - files@eliterecoverymn.com IP 75.73.105.200
January 5, 2021 11:18 am CSTMichelle Wolff - michelle@eliterecoverymn.com added by Justin Scharr - justin@eliterecoverymn.com as a CC'd Recipient Ip: 24.118.59.35
January 14, 2021 10:18 am CSTMichelle Wolff - michelle@eliterecoverymn.com added by Justin Scharr - justin@eliterecoverymn.com as a CC'd Recipient Ip: 24.118.59.35
February 23, 2021 8:47 am CSTElite Files - files@eliterecoverymn.com added by Justin Scharr - justin@eliterecoverymn.com as a CC'd Recipient Ip: 24.118.59.35
February 21, 2024 12:41 pm CSTElite Files - files@eliterecoverymn.com added by Justin Scharr - files@eliterecoverymn.com as a CC'd Recipient Ip: 75.73.105.200
February 21, 2024 12:41 pm CSTElite Files - files@eliterecoverymn.com added by Justin Scharr - files@eliterecoverymn.com as a CC'd Recipient Ip: 75.73.105.200
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https://www.eliterecoverymn.com/
Audit Trail Serial# fd29fc649562e3f8f54f01b13427ca4d