Restoration Family Services Forms

“Helping families provide missing pieces”

Welcome to the Restoration Family Services, Inc.’s “Service Forms” platform.

 

Please fill in all required fields *:

 

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RFS AUTHORIZATION FOR THE DISCLOSURE AND RECIPROCAL EXCHANGE OF PROTECTED HEALTH INFORMATION (PHI)


    I (Client or Legally Responsible Person [LRP]), hereby authorize Restoration Family Services, Inc. (RFS) to share specified Protected Health Information (PHI) with the following agency or individual:*




    Protected Health Information will be disclosed/exchanged for the purpose of:

    Only the following information selected by the client or LRP shall be disclosed:


    My right to confidentiality has been explained to me and I understand the information to be released, the purpose of the release, and the statues and regulations protecting my confidentiality. I understand that I may revoke this authorization to disclose PHI at any time, either verbally or in writing, except where disclosure based upon it has already occurred. I understand that the information to be disclosed may include information regarding drug abuse, alcohol abuse, HIV infection, AIDS or AIDS related conditions, psychological, psychiatric, or physical impairments, if specifically authorized above.

    I understand that the above recipient party, without my further consent, may not release this information. RFS is required by HIPAA privacy law to protect my health information. However, once RFS discloses information, I understand RFS has no control over my privacy with regard to the recipient of the information.

    This authorization will automatically expire one year from signature date or 90 days after discharge from services, whichever comes first. I may request a copy of this authorization. RFS will provide treatment to me whether or not I sign this release.

    Legally Responsible Person / Adult Consumer
    Please write your signature in the box below:*




    * Client must sign (or legally responsible person) and information is protected by Federal Regulations 42CFR part 2. Confidential information relative to a client with HIV infection, AIDS related conditions shall only be released in accordance with G.S. 130A-143. A clear and legible photocopy of this consent must be kept in the client’s medical record.


    Stand: 03/19/2021

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