I understand that my records are protected under Federal and/or Washington State Law and cannot be disclosed without my written consent unless otherwise provided for in the regulations (including 45 C.F.R Pts. 160 [HIPAA] and 42 C.F.R Part 2 [if I am receiving chemical dependency treatment services]). I also understand that my written consent is required to release any health care information relation to testing/diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, an alcohol or other drug use unless otherwise provided in the regulations. If I have been tested, diagnosed or treated for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, and/or alcohol or other drug use, you are specifically authorized to release all health care information relating to such diagnosis, testing, or treatments as indicated above. I understand that once the above information is disclosed, it may be re-disclosed by the recipient (except when prohibited) and the information may not be protected by federal privacy laws or regulations. I understand that I do not have to sign this authorization in order to receive health care benefits (treatment, payment, enrollment, or eligibility for benefits) except for health care services necessary to create any assessment or report for disclosure to the recipient identified in this authorization. *This authorization may be revoked at any time in writing, except to the extent that action has already been taken in reliance on it.
Patient / Legal Representative Signature
Provider / representative Signature
1446 Spaulding Park, Suite 303, Richland, WA 99352
After Hours: 509.845.4515
Working Hours: Monday - Friday: 9am - 6pm
Saturday & Sunday: Closed
128 N 2nd Ave Suite 209, Walla Walla WA 99362