Medical and BH ROI (Legal)

Authorization for Disclosure of Protected Health Information (for LEGAL ENTITIES OR ACTIVITY)

Spectra Health Medical Clinic & Behavioral Health Services
Patient Demographic Information
Patient Name

First NameLast Name
patient name print
Patient Date of Birth

MonthDayYear
patient dob print

MonthDayYear
Date
Patient Address

Street Address

Street Address Line 2

CityState

Zip Code
Patient Phone Number
Phone number with area codeFormat: (000) 000-0000.
Patient Email
email@domain.com
Authorization and Third Party Organization Designation
This form authorizes Spectra Health to:
Name of Third Party/Outside Organization
Address of Third Party/Outside Organization

Street Address

Street Address Line 2

CityState

Zip Code
third party address print
Third Party's Phone Number
Phone number with area codeFormat: (000) 000-0000.
Third Party's Fax Number
Fax number with area codeFormat: (000) 000-0000.
Third Party's Email
email@domain.com
Disclosure Information and Purpose
INFORMATION TO BE DISCLOSED (mark all applicable categories):

Other
General Time Period Release - FROM

MonthDayYear
General Time Period Release - TO

MonthDayYear
from print
to print
PURPOSE FOR DISCLOSURE:

Civil, Criminal, Administrative, or Legislative Investigation or proceeding against the client named
SUBSTANCE USE DISORDER TREATMENT INFORMATION
Substance Use Disorder treatment records - Please read the following statements carefully:
I am authorizing disclosure of my Substance Use Disorder Treatment (SUD) information contained in the information selected or as described in this authorization
In accordance with North Dakota state law, minor patients over the age of 14 must sign this disclosure and consent to the release of their protected substance use disorder treatment information.
Authorization Expiration
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.

This authorization is valid for one year from the date signed if not previously revoked or otherwise specified.
Would you like to specify an expiration date for this authorization?
Expiration Date

MonthDayYear
expiration date print

MonthDayYear
Enter a future date
Signature
ARCHIVED Patient Signature
Patient Signature
Date of Patient Signature

MonthDayYear
Today's Date
ARCHIVED Signature of Guardian or Authorized Representative
Guardian or Authorized Representative Signature
Date of Signature of Guardian or Authorized Representative

MonthDayYear
Today's Date
ARCHIVED Witness Signature
Witness Signature
Date of Witness Signature

MonthDayYear
Today's Date
sender name
sender email
current date print

MonthDayYear
Date
Should be Empty:

Authorization for Disclosure of Protected Health Information (for LEGAL ENTITIES OR ACTIVITY)

Patient Demographic Information

Authorization and Third Party Organization Designation

Disclosure Information and Purpose

SUBSTANCE USE DISORDER TREATMENT INFORMATION

Authorization Expiration

Signature