Client Contact Information:

    Guardian or Legal Representative Contact Information:

    I hereby authorize Noah’s Ark Child and Family Treatment center to release all health information about me.

    Noah's Ark Child and Family Treatment Center
    1728 5th Avenue North
    Birmingham, AL 35203

    Phone Number:
    Fax Number:

    The following person/organization is hereby authorized to receive my entire medical record, treatment record and diagnostic record to the following person or organization:

    By my signature below, I acknowledge that any prior agreement I have made to restrict or limit the disclosure of information about my health does not apply to this authorization.

    The following health information that relates to service beginning from

    , may be released:

    -Entire Medical Record including patient histories, office notes (except psychotherapy notes), test results,referrals, consults, billing records, insurance records, and records sent by other health care providers.
    -Patient Histories
    -Office Notes (except psychotherapy notes)
    -Test Results
    -Billing Records
    -Insurance Records
    -Records Sent by Other Health Care Providers

    I further understand that my medical record may include one or more of the following:
    -Mental Health Information or Psychological Conditions
    -Alcohol or Substance Abuse Treatment

    I understand that once this form is complete, it will take 7 Business Days before the records can be picked up in the office by the client/guardian(over age 18), faxed or emailed.

    How would you like to receive a copy of the NACFTC records?(Check all that apply)

    Pick up in officeEmailFax

    I understand and agree that health information about me, which is used or disclosed pursuant to this authorization, may be subject to re-disclosure by the recipient and may no longer be protected by law.

    This authorization is valid for 24 months following the date of my signature shown below.

    A copy, electronic copy, image, or facsimile of this authorization is as valid as the original.

    I have the right to revoke this authorization in writing at any time.

    I acknowledge that such a revocation is not effective to the extent the above person/organization has relied on the use or disclosure of my health information. I have read (or have had read to me) this authorization, and I agree to its terms as indicated by my signature below.I am entitled to a copy of this authorization.