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.