AUTHORIZATION TO RELEASE MEDICAL RECORDS

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.

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

Phone Number:
205-502-7278
Fax Number:
205-502-7779

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

to
, 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
-Referrals
-Consults
-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
-PsychologicalTesting

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.