Spectra Health Behavioral Health ROI 2024

RELEASE OF CONFIDENTIAL BEHAVIORAL HEALTH, ALCOHOL AND/OR DRUG TREATMENT RELATED INFORMATION

212 S 4th St Ste 200, Grand Forks, ND 58201 - Records Fax (701) 757-2811 - Clinic Phone (701) 757-2100 - Records Phone (701)757-2810 - Records@SpectraHealth.org

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Spectra Health acknowledges that the provision of the services is not contingent upon the client's decision concerning the release of this information. This consent is subject to revocation at anytime except to the extent that the program which is to make the disclosure has already taken action in reliance on it. A copy of this release is as effective as the original If not previously revoked, this consent will terminate upon:*
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NOTICE TO WHOEVER DISCLOSURE IS MADE: This informaton has been disclosed to you from records protected by Federal confidental rules (42 CFR Part 2)
and the Health Insurance Portability and Accountability Act of 1966 (HIPAA), 45 CFR, parts 160 and 164. The Federal rules restrict any use of the informaton
to criminally investgate or prosecute any alcohol or drug abuse patent.
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RELEASE OF CONFIDENTIAL BEHAVIORAL HEALTH, ALCOHOL AND/OR DRUG TREATMENT RELATED INFORMATION