Cornerstone Recovery and Supports, Inc501 7th Avenue, Beaver Falls, PA 15010

Authorization for Use/Disclosure of Personal Health Information

1. I hereby authorize ______________________________________________________ FACILITY/PROGRAM NAME/ADDRESS______________________________________________________________________to use/disclose the following Protected Health Information from the records of:Name _______________________________________________________________Address ________________________________________________________________ ________________________________________________________________Date of Birth _______________________ Telephone __________________________

2. Information to be Used/Disclosed Psychiatric Evaluation Medical History Annual Physical Social History Discharge Summary Course of Treatment Treatment Care Plan Neurological Reports

Medication History Psychological/Achievement Test Specify Dates: __________

Individual Support Plan Progress Notes Physician’s Report Current Medications

Other (specify): ________________________________________________________

3. This information is being disclosed to : ________________________________________ for the following purpose:

Intake/Assessment Locating/coordinating/monitoring services Planning for Treatment Case Management Referral At the Request of the Individual Continuity of Care/Services Other (specify): _______________________________________________________________

4. I understand this authorization may be revoked verbally or in writing at any time, except to the extent that action has been taken in reliance on this authorization.

5. Cornerstone Recovery and Supports, its programs, services, employees, officers, and contractors are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized.6. I understand that Cornerstone Recovery and Supports will not condition treatment, payment, enrollment or eligibility on the provision of this authorization.

Name: ______________________________________________

7. I understand that I may inspect or copy my personal health information and may choose not to sign this authorization.

8. I understand that information should not be re-disclosed without authorization unless otherwise provided for by law/regulation.

9. I understand that information to be released from the above-named facility/program records includes photocopies relating to my identity, diagnosis, prognosis and treatment.

10. I understand this disclosure may include information related to psychiatric disorder and Acquired Immunodeficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) so long as the disclosure is in keeping with the Mental Health Procedures Act of 1976 and Act 148 Confidentiality of HIV=Related Information and the Standards for Privacy of Identifiable Health Information 45 CFR Parts 160 and 164 of the 1996 Health Insurance Portability and Accountability Act (HIPAA).

11. I understand that disclosure may include drug or alcohol information and/or diagnosis and is protected under federal regulations governing confidentiality of alcohol and drug abuse patient records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

12. Unless otherwise revoked, this authorization is in effect from____________________ until ___________________ (not to exceed 365 days).SPECIFY DATE SPECIFY DATE

13. I agree to the conditions of this authorization. I have been offered a copy of this form which I have accepted denied.

____________________________________________________________________________________SIGNATURE OF INDIVIDUAL DATE

____________________________________________________________________________________SIGNATURE OF PARENT LEGAL GUARDIAN PERSONAL REPRESENTATIVE

(SPECIFY AND DATE) ______________________

____________________________________________________________________________________SIGNATURE OF WITNESS DATE