Disclosure Authorization

Client: ________________________________________  Admission Date: ______________

Resident at: _____________________________________ Date of Birth: ________________

AUTHORIZATION TO USE OR DISCLOSE PROTECTED IN INFORMATION

I authorize the use or disclosure of information as to my status as a resident at one of the Foundations in Recovery program homes. This information is to pertain to the level of my participation in, and compliance with, the program guidelines which includes the results of drug and alcohol screening and any medical emergencies. The person(s) and/or entities to whom the information may be disclosed include the following:

Name:__________________________________Relationship:_________________________

Address: _______________________ City, State and Zip:____________________________

Phone Number: __________________________ Fax: ____________________________

 

Name:__________________________________Relationship:_________________________

Address: _______________________ City, State and Zip:____________________________

Phone Number: __________________________ Fax: ____________________________

 

Name:__________________________________Relationship:_________________________

Address: _______________________ City, State and Zip:____________________________

Phone Number: __________________________ Fax: ____________________________

DISCLOSURE COMMUNICATIONS SHALL BE LIMITED TO: ___ Verbal Contact ___ Written Contact

THIS ____ A SINGLE OR ____ A CONTINUING DISCLOSURE (Initial the appropriate box)

I have been informed of the specific type(s) of information that may be requested and of the benefits and/or disadvantages of releasing the above information. I understand that this release will remain in full force throughout my stay at a Foundations In Recovery facility, unless otherwise specified by me in writing. I understand that this consent is subject to revocation by me at any time except to the extent that action has been taken in reliance on this consent prior to revocation and unless referred by the criminal justice system. Revocation of authorization must be presented to Foundations in Recovery in writing. I absolve Foundations in Recovery from any and all damages, claims, causes of action arising out of or in connection with, the release of this information. The protected information used or disclosed may be subject to re-disclosure by the recipient and is no longer protected.

Client Signature: ___________________________________ Dated: _____

Witnessed by: _____________________________________ Dated: _____

Download Disclosure Authorization form for Foundations in Recovery, LLC

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