Renaissance Ranch Ogden Authorization for Release of Information

  • I understand this consent will remain in effect for (1) one year from the date of signing. I understand that all information given under this consent is protected under the Federal Confidentiality regulations (Title 42 CFR part 2 of the US code and HIPPA Act of 1996, 45 CFR parts 160 and 164, Privacy and Security regulations) and cannot be disclosed without my written consent unless otherwise provided for in this regulation.
  • The following notice will Accompany Any Disclosure

     
    This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR part 2)
     
    The Federal rule prohibits you of making any further disclosure of this information unless further disclosure is expressly 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 an alcohol or drug patient.
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