Authorization to Release and Disclose Patient Information The Road 2 Recovery Foundation

A. Patient Information

Name

First Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

B. Authorization of Release of Protected Health Information

I hereby authorize The Road 2 Recovery Foundation full access; use and disclose my complete health record, including records relating to any mental healthcare, communicable diseases (e.g. HIV or AIDS) and treatment of alcohol or drug abuse, health information in compliance with state and federal law. This authorization shall be in force and effect for one year, unless I specify a different expiration here, in which case this authorization expires upon the occurrence of that event or date.*

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Alternative Expiration:

Signature*

Please type your name to sign

Date*

C. Revocation

I understand that I have the right to revoke this authorization in writing at any time. I understand that a revocation shall not be effective to the extent that any person or entity has already acted in reliance on my authorization.*

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D. Not Restriction on Treatment

I understand that my ability to obtain treatment will not be conditioned on whether I sign this authorization.*

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E. Further Disclosures

Are you the legal guardian?*

Yes
No

please attach documentation of the legal guardian’s authority to act on behalf of the patient.

Max. file size: 50 MB.

I understand and acknowledge that Road 2 Recovery Foundation may re-disclose my protected health information described above in accordance with state and federal law and that Road 2 Recovery Foundation cannot prevent re-disclosure of my protected health information described above by the person or organization who may receive my protected health information from Road 2 Recovery Foundation. By signing this authorization, I release Road 2 Recovery Foundation from any and all liability resulting from a re-disclosure by the recipient. I understand and acknowledge that my signature indicates that I have read and understand this form, and authorize release of my protected health information as described above.*

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F. I understand and accept the Road 2 Recovery funding percentage hold back of 10% off all funds collected in my name via online or at at fundraising event. This hold back is to cover all cost associated with the funding campaign of my account. I am aware of the payout policy of Road 2 Recovery and accept that no funds will be paid to me directly but will be paid out to all medical providers, approved expenses and needs.*

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(Patient or Legal Guardian Printed Name)*