I authorize the above-named healthcare provider to disclose the requested medical information to the organization/individual named on this request. I understand that my records are protected under Federal Confidentiality Regulations (42 CFR part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations.
I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions. I understand that I may revoke this authorization at any time upon a written notice to Granite Recovery Centers, Attn: Medical Records, 6 Manor Parkway, Salem, NH, 03079. Or email the request to medicalrecords@graniterecoverycenters.com.
This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosures expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client. I understand I may see and obtain a copy of the information described on this form, and a reasonable copy fee may be charged. I understand that I may have a copy of the signed authorization form.