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Release of Information Form

If you prefer to complete the form offline, you may download and print a copy by clicking the link below. Once completed, you can drop off in our office mailbox, fax it to 973-584-4991 or submit the completed forms through the submit button below.

Download Release of Information Form

AUTHORIZATION OF RELEASE FOR CONFIDENTIAL INFORMATION

This authorization automatically expires at discharge or termination of treatment. I understand that upon this expiration date, MT. OLIVE COUNSELING & CLINIC will no longer provide my information to the person stated above, and that if I wish for this person to continue to receive information, I must execute another authorization. I understand that if the above-named person is not a health care provider or part of a health plan covered by federal privacy regulations, my health information may not be re-disclosed to the person and will no longer be protected by these regulations. However, the person named above may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

I understand that if I refuse to sign this form, MT. OLIVE COUNSELING & CLINIC will not disclose my information to the person named above. I understand I may revoke this authorization at any time, in writing, except to the extent MT. OLIVE COUNSELING & CLINIC has acted in reliance on this authorization. A written request to revoke this authorization must be provided to MT. OLIVE COUNSELING & CLINIC. The revocation will be effective on the date MT. OLIVE COUNSELING & CLINIC receives the notification.

Addendum

Substance Abuse Information Only:

Further, I understand that if I am authorizing MT. OLIVE COUNSELING & CLINIC to disclose information about substance abuse, I must state the purpose of the disclosure.

I consent for any or all the following information to be released:
1. Addiction Severity Index (ASI)
2. Biopsychosocial Assessment
3. Current Medications
4. Discharge Summary
5. HIV Test Results
6. Medical and Physical Examination
7. Medical Test Results
8. Program Admission/ Discharge
9. Program Attendance
10. Psychiatric or Psychological Evaluation
11. Psychiatric or Psychological
12. Progress/ Reports
13. Treatment Diagnosis
14. Treatment Plan
15. Treatment Prognosis
16. Treatment Status/ Progress
17. Urine Drug Screen Result
18. Other

The Federal Regulations (42 CFR Part 2) prohibit any further release of this information in cases of patient's suffering from Mental Health (see below).

(Copy of Valid Appointment of Guardianship or Power of Attorney must be attached)

This information has been disclosed to you from records whose confidentiality is protected by Federal and State law Federal Regulations and Statutes (42 CPR-Part 2) and New Jersey State Statutes (N.J.S.A 26:2B-15) prohibits you from any further disclosure of it without the express written consent of the person to whom it pertains, or as otherwise permitted by such regulations and statutes. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

Use separate form submission for each chain of custody.

The electronic copy of the document will be delivered to your designated email address.