Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>Release of Information Authorization</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_FirstName"><i class="fa fa-font"></i><label class="er_fld_label">Youth First Name</label><input name="CST_36" type="text" class="" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_LastName"><i class="fa fa-font"></i><label class="er_fld_label">Youth Last Name</label><input name="CST_37" type="text" class="" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 33.3333%;" map_to="CC_DOB"><i class="fa fa-font"></i><label class="er_fld_label">Date of Birth</label><input name="CST_2" type="text" class="er_fld_width50" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_SSN"><i class="fa fa-font"></i><label class="er_fld_label">SSN#</label><input name="CST_4" type="text" class="er_fld_width50" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col1" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">I hereby authorize Presbyterian Hospitality House:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="to Exchange with">to Exchange with</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="to Release to">to Release to</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_5" value="to Exchange verbal information with">to Exchange verbal information with</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_5" value="Other:">Other:<input class="cst_Other" name="CST_5_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">Name of Person/Agency</label><input name="CST_9" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">Address, City, State, Zip Code</label><input name="CST_10" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">Phone Number, Fax Number</label><input name="CST_11" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;"><i class="fa fa-font"></i><label class="er_fld_label">Email</label><input name="CST_32" type="text" class="er_fld_width50"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">1. The following specific information: Please select each item that you authorize us to exchange or release.</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Behavioral Health Assessment">Behavioral Health Assessment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Psychiatric Evaluation ">Psychiatric Evaluation </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Substance Abuse Assessment">Substance Abuse Assessment</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Neuropsychological Evaluation">Neuropsychological Evaluation</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Medication Sheets">Medication Sheets</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Verbal Exchange of Information">Verbal Exchange of Information</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Social History">Social History</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Medical History & Physical">Medical History & Physical</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="School Records ">School Records </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Immunization Records">Immunization Records</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Progress Notes">Progress Notes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Treatment Plan">Treatment Plan</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Treatment Plan Reviews">Treatment Plan Reviews</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Discharge Summary">Discharge Summary</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="UA Results">UA Results</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_12" value="Incident Reports">Incident Reports</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_12" value="Other:">Other:<input class="cst_Other" name="CST_12_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">2. The purpose of the release of this information is:</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Sharing with other health care providers as needed">Sharing with other health care providers as needed</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="My personal records">My personal records</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Insurance/Billing Purposes">Insurance/Billing Purposes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_13" value="Legal">Legal</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_13" value="Other:">Other:<input class="cst_Other" name="CST_13_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">I understand that the information in my health record may include information relating to acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. Exchange of information ensures continuity of care between providers. By not sharing information, my health care could be compromised. I hereby authorize the use or disclosure of my health care and/or other information as described above. I understand that this authorization is voluntary. I understand that I may revoke this authorization at any time by notifying the individual(s) or organization releasing this information in writing, but if I do, it won’t have any effect on actions taken on this authorization before my revocation was received. I understand that the individual(s) or organization releasing this information will not condition my treatment, payment, enrollment in a health plan (if applicable) or eligibility for benefits on whether I provide this authorization. I understand that if the person(s) or organization authorized to receive this information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. To the extent that this information is required to remain confidential by federal or state law, the recipient of this information must continue to keep this information confidential. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;"><i class="fa fa-calendar"></i><label class="er_fld_label">3. This authorization expires on the following date or event or 365 days from the date of signature if no other date or event is indicated. Photo static and/or facsimile copies of this authorization will be considered as valid as the original.</label><input class="cst_datepicker er_fld_width25" name="CST_35" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Signatures</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"><i class="fa fa-font"></i><label class="er_fld_label">Parent/Legal Guardian/Placement Worker Printed Name</label><input name="CST_33" type="text" class="er_fld_width100" value="<*EN1>"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;"><i class="fa fa-font"></i><label class="er_fld_label">Relationship to client/Title</label><input name="CST_26" type="text" value="" class="er_fld_width100"></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"><i class="fa fa-pencil"></i><label class="er_fld_label">Parent/Legal Guardian/Placement Worker Signature</label><div class="cst_signaturepad"></div><input name="CST_25" type="text" class="" field_code="<*ES1>"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;"><i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_width100" name="CST_24" type="text" value="<*ED1>"></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"><i class="fa fa-pencil"></i><label class="er_fld_label">Youth Signature</label><div class="cst_signaturepad"></div><input name="CST_23" type="text" class="" field_code="<*ES2>"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;"><i class="fa fa-calendar"></i><label class="er_fld_label">Date</label><input class="cst_datepicker er_fld_width25" name="CST_27" type="text" value="<*ED2>"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"><i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">RECIPIENT INFORMATION: If the information released pertains to alcohol or drug abuse, the confidentiality of the information is protected by federal law (CFR 42 Part 2) prohibiting you from making any further disclosure of this information without the specific written authorization of the person to whom it pertains or as otherwise permitted by CFR 42 Part 2. A general authorization for the release of medical or other information if held by another party 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. </div></li></ul>
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