Release of Information – Client Use this form to document your consent for our communication of your confidential information with other individuals or agencies. Electronic modes of communication are not necessarily secure and can put your privacy at risk. Following is Elite Recovery LLC’s policy on electronic communication. Should you have any questions, please feel free to discuss them with a staff member at any time. Email Communications: Email is not a secure form of communication. We use email communication for administrative purposes, forms and consents and appointment reminders, unless we have made another agreement. If you choose to email us about clinical matters and request or expect a clinical response, it is at your own risk. Ideally clinical matters should wait to be discussed at your next session or over the telephone. Email communication is also used to send links for the review and signing of electronic consent and intake forms, and by entering your email in any form on our website you are accepting responsibility for the management of any information sent via unsecure email. Please do not enter your email in this form if others have access to your email account, or if you do not want protected health information sent via email communication. Text Communications Text messaging is a very unsecure mode of communication. Should you consent, we will use text messaging to send regular appointment reminders, to cancel a session at the last minute, or communicate about other more time-sensitive matters. We might also text to alert you to an email that we’ve sent that is time-sensitive. If you choose to text us, be aware that text lines are not constantly monitored and you may not get a reply expeditiously. Texting should be limited to appointment and administrative issues, and should not contain clinical content. By entering your phone number into this form, you are consenting to receive text messages for the purposes defined in this section. Please consent to electronic communication first:Consent* By checking this box you are consenting to electronic communication. I consent to electronic communication.Which staff member should receive this release when you're done?Select a Staff Member:*If you are already receiving services, please select the staff member with whom you are working. If not, you may skip this step.Select Staff MemberStaffAlyssa Larson – CounselorAndrew Dolan – CPRSAnna Lipinski – Treatment DirectorAshley Dank – CounselorBetsey Degree – AssessmentsBreanna Dedeker – CounselorBrittany Moselle – CounselorChoice Pickins Newstrom – CounselorCiera Spencer – Utilization Review SpecialistEva Christensen – Treatment DirectorJackelyn Pike – CounselorJalisa Glynn – Treatment CoordinatorJill Traynor – CounselorKarla Selness – CounselorKaren Johnson – CounselorKatherine Mikkelson – Treatment CoordinatorLinda Towle – CPRSMeg Coughlin – CounselorMichelle Wolff – AdmissionsNicki Zeidner – NutritionistNicole Friend – Executive Treatment DirectorMike O'Brien – CounselorPatrick Johnson – CounselorPeter Hanson – CounselorRichard McCullough – CounselorSamuel Polivick – Treatment CoordinatorSean Graham – CounselorSpencer Melby – AssessmentsTaharah Hovey – AssessmentsTerrance McDonald – CounselorTracy Flynn – Access TeamAdvantage StaffOtherClient InformationClient Name:* First Last Client's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920eMail Address:*A signed copy of this authorization will be sent to this email. Agency/Person for whom the release is being signedAre you signing a release for a personal contact like a significant other, or a business/agency? * Personal Contact Business/Agency Agency Name:Required if “business/agency” is selected above. Contact Person's Name:Required if “personal contact” is selected above. First Last Relationship:*Who is this person to you? friend, coworker, therapist, etc Contact Phone:Contact Fax:Contact eMail: Contact or Business/Agency Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Nature & Purpose of DisclosureHow may we exchange information with this contact? ** Deselect All provide to receive from exchange with What type of information may we exchange?*The most common options are pre-selected. Please check/uncheck options to match your preference. Select All Summary of Chemical Health Services Discharge Summary & Recommendations Summary of Mental Health Treatment Services Ongoing Reports on Treatment Progress Diagnostic Assessment Results of alcohol/drug screening test Treatment Plan Relevant Medical Information Results of Chemical Use Assessment Billing Records Results of Psychological Testing Chemical Dependency Treatment Notes Psychotherapy Notes Other Other information type: In what format may we exchange information?* Deselect All Verbally In-Person Conference Written Questionnaire Mailed/Faxed Correspondence Secure/Encrypted eMail Reason for releasing information:* Select All Client Access to Services Social Security Disability Process Treatment/Continued Care Insurance Payment Assessment & Referral Other: Other Reason: Expiration of AuthorizationTypically, releases of information automatically expire one year from the date signed. This allows us to share the necessary information for the duration of treatment involvement. If you wish to specify an earlier date of expiration, you may do so here. I Don’t Need to Change the Expiration Enter a Different Date Alternate Expiration Date MM slash DD slash YYYY SignaturesYou will sign twice. Once below, and then again on the next page. Sign Here to Authorize Disclosure:*Your signature here attests to your agreement with the information on this form and authorization of disclosure of your protected health information pursuant to the restrictions, routes, methods and details contained.CommentsThis field is for validation purposes and should be left unchanged.
