Roots ROI - Client Self-Service


393 Dunlap St N, Ste 300
Saint Paul, MN 55104
ph 612.564.5933
fax 612.564.5932

 

Authorization for the Release of Protected Health Information

Client Name:   
Client Date of Birth:  

 

By signing this form, I hereby authorize Minnesota CarePartner/Roots Recovery, to:   





The following information:     

I consent to this information being shared in the following manner:     

The purpose for this disclosure is:     

I understand that:

  • My health information is protected by federal regulation (Alcohol and Drug Abuse Patient Records, 42 CFR Part 2: and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Minnesota CarePartner/ Roots Recovery's Privacy Notice. I understand that I have a right to inspect and receive a copy of my treatment records that may be disclosed to others, as provided under applicable state and federal
  • I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Minnesota CarePartner/Roots Recovery's Privacy Notice outlines the procedure for revocation. This authorization will expire in one year from the date I sign or unless I request an earlier expiration by entering a desired date here:  
  • For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) (45 CFR & 164.508 (b)(4)(III)
  • Communications resulting from this authorization will reveal that I receive services at Minnesota CarePartner/Roots Recovery.
  • Federal confidentiality regulations (at 42 CFR Part 2) prohibit re-disclosure of information from alcohol and drug abuse patient records. However, HIPAA requires Minnesota CarePartner/Roots Recovery's to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules.
  • This authorization may be used by Minnesota CarePartner/Roots Recovery's owned or managed programs upon transfer of my care to them.
  • This information is confidential and will only be used for business purposes and then shredded after 7 years as regulated by HIPAA/confidentiality laws below:

STATUTORY NOTICE:
Information to be disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Roots ROI - Client Self-Service
lock iconUnique Document ID: 427e1cc159f57618a75e78af85c342309207a476
Timestamp Audit
January 18, 2020 7:31 pm CSTRoots ROI - Client Self-Service Uploaded by Justin Scharr - justinscharr@mncarepartner.com IP 71.34.15.87
January 18, 2020 7:35 pm CSTRoots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 75.72.214.61
April 19, 2020 1:57 pm CSTRoots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 75.72.214.61
May 27, 2020 9:18 am CSTRoots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
January 1, 2021 12:02 pm CSTRoots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 71.34.15.87
January 1, 2021 12:04 pm CSTRoots Forms - rootsforms@mncarepartner.com added by Justin Scharr - justinscharr@mncarepartner.com as a CC'd Recipient Ip: 71.34.15.87