Release of Information

Patient Information

Releasing Party

Release Purpose

Information to be Released

Method of Release

Note: I acknowledge that by electing to receive my health information via e-mail in a non-secure manner that the information is not encrypted and that it could be intercepted and viewed by a third party. Crestpoint Wellness and Horowitz Health are not responsible for unauthorized access to your health information while in transmission to the e-mail address you designated above.

Note

By signing this authorization, you grant permission for the release of your information, which will remain valid for one year from the date of your signature, unless a different date or expiration is specified. This authorization can be revoked in writing at any time; however, any releases that occur prior to the revocation will still apply. It is important to note that declining to sign this authorization will not impede your access to treatment. Copies or faxes of this authorization hold the same weight as the original. Your records may encompass information received from other organizations, and if such records have been incorporated into your file at Crestpoint Wellness, they may also be disclosed. Keep in mind that Crestpoint Wellness cannot control the subsequent sharing of your information by the recipient, and this data may not retain the same state and federal privacy protections once it is released. By signing, you release Crestpoint Wellness from any liability stemming from the recipient's redisclosure of the information. Notably, under 42 CFR Part 2, unauthorized disclosure of substance use records is prohibited. Your signature signifies your comprehension of- and agreement with- the contents of this form, authorizing the release of your information as detailed above.