Consent for Release of Confidential Information


I, , born, , authorize Cirque Lodge to release and/or request the following information, so indicated by my signature below.

The purpose of this disclosure is:

Any re-disclosure of record information is prohibited by federal regulation 42CFR, Part 2.

I agree to be responsible for payment of gathering, retrieving, and photocopying the indicated records.

This authorization for release of information is valid from this date to . If no date is specified, this consent shall expire one year from signature date.

I may revoke this consent to release information at any time, except where actions have already been taken on the basis of this consent. I have been informed of the specific types of information that have been requested and give my consent freely and voluntarily. Treatment services are not contingent upon whether the information is released or not. A photocopy of this authorization is considered acceptable in lieu of the original. Information to be released shall include all confidential HIV related information (A.R.S. section 35-661), confidential communicable disease related information (A.R.S. 35-661) and alcohol or drug abuse related information.

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Signature Certificate
Document name: Consent for Release of Confidential Information
Unique Document ID: 49fafb34e12887e60d1d2bd15cb56e504f6c94dd
Timestamp Audit
2016-06-20 09:24:30 MDTConsent for Release of Confidential Information Uploaded by Courtney McShay Carroll - information@cirquelodge.com IP 205.204.44.102