Release of Information

Thank you for Signing the Statement of Patient Rights

Primary Care Intake Paperwork – Step 5 (optional)

If you would like to authorize the release of your information to a third party, please complete the form below.

Thank you for Signing the Patient Complaint & Grievance Process

Step 5: Release of Information (optional)

If you would like to authorize the release of your information to a third party, please complete the form below.

Thank you for Signing the Statement of Patient Rights

Step 5: Release of Information (optional)

If you would like to authorize the release of your information to a third party, please complete the form below.

If a minor is 14 years or older, they must sign the release form below or have a Release of Information (ROI) form on file for the signing parent.

I hereby request and authorize the release of medical, mental health, & substance abuse records of:

Patient

Patient Name*

First Last

Patient Date of Birth*

Patient Telephone*

Patient SSN

Person Receiving Permission

Name of Person with Permission*

First Last

Address

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

Phone*

Fax

The Person receiving permission is:*

Family/Friend
Healthcare Facility/Provider
Other

Relation to Patient

They have permission to:*

(a) Schedule, change or cancel appointments only and/or
(b) Speak with Sage about patient’s medical condition

Check all that apply

All Releases Expire After One Year

By signing this, I am in agreement to the release of information between Sage Neuroscience Center and its providers and the above listed individual/health care providers. I am aware that this release is strictly limited to the contents of my records as checked above. I understand that information regarding active suicidal and homicidal ideation or other known or suspected harm to self or others is not protected under the Health Information Privacy and Portability Act (HIPAA). Disclosing such information is at the discretion of Sage Neuroscience Center to release and would be done so strictly to ensure safety and security. I do not have to sign this authorization in order to receive treatment from Sage Neuroscience Center. I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I agree not to hold Sage Neuroscience Center liable for such third-party disclosure. I have the right to revoke this authorization in writing (except to the extent that Sage Neuroscience Center has already acted in response to this authorization), which must be submitted to the Office Manager at the above address. PROHIBITION OF REDISCLOSURE: Federal regulations (42 CFR Part 2) and State Laws (NMSA 1978 43-1-19, 32A-6A-24, 24-2B-7, and 24- 1-9.5) prohibit further disclosure of mental health or alcohol and/or drug abuse treatment information, and the results of tests for HIV/AIDS and other sexually transmitted diseases to any person or agency without securing another proper written authorization for that purpose, or otherwise permitted by Federal regulations or State laws.

Informed Consent

I, the patient, am capable of informed consent and 14 years or older.

**If the patient is a minor (under 14) or incapable of informed consent, DO NO Confirm this box and include your relation below.**

Parent or Legal Guardian

I am signing this release form as the Parent and/or Guardian of the patient.

Signature Name*

Relation to Patient

Signature*

CAPTCHA

Thank you for Signing the Statement of Patient Rights

Primary Care Intake Paperwork – Step 5 (optional)

Thank you for Signing the Patient Complaint & Grievance Process

Step 5: Release of Information (optional)

Thank you for Signing the Statement of Patient Rights

Step 5: Release of Information (optional)

I hereby request and authorize the release of medical, mental health, & substance abuse records of:

Patient

Person Receiving Permission

All Releases Expire After One Year

For more information about our services, contact us today at

Our mission is to provide comprehensive behavioral health and substance use treatment to the community. We empower individuals to achieve health, wellness and recovery.

The Expert: Sage Behavioral Health Blog