Community Resources Services Medical Services Dr. Kristine McVea, M.D. Dental Services Pharmacy Services Access Services Other Services Services Overview Medical Services Behavioral Health Services Dental Services Pharmacy Services Access Services Other Services CONSENT FOR RELEASE OF INFORMATION ALL CARE HEALTH CENTER 902 South 6th Street Council Bluffs, IA 51501 Phone : 712-325-1990 Fax :712-325-0288 Patient’s Legal Name * settings Birth Date * settings Patient Address settings Patient Phone Number settings The information will be settings - Choose - sent to released from By signing this form, I am allowing ACHC to RELEASE or RECEIVE medical information concerning the above named patient via: settings - Choose - Pick Up Fax Verbal Electronic Device Name of person or institution settings Phone Number * settings Fax Number settings Address * settings Note: if this notice accompanies a disclosure of information concerning a patient in alcohol and drug treatment, made to you by the consent of such patient, the following will apply. This information has been disclosed to you from records that are protected by Federal confidentiality rules (42 C.F.R. Part 2). The Federal rules prohibit you from making any further disclosure of information in this record that identified a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 C.F.R. 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 client. Check the information to be disclosed * settings Medication list Allergy list Immunization record Problem List (Pt. Summary list) History and Physical Discharge summary Laboratory results X-ray and imaging reports Consultation reports Test results (e.g. EKG, PFT, etc.) Billing Information Other Please list specific dates, clinic, doctors, or types of reports your are looking for. settings Provide a date by which the info is needed: settings Please indicate the reason for release * settings Insurance 2nd Option Rehab/disability Personal file Moving out of area Legal Other medical care Transfer of care If transferring care, may we confidentially discuss with you? settings Yes No If yes, please indicate the best time and telephone number to reach you: settings This authorization is voluntary. If I choose to cancel this consent at a later date, I must send written notification to the Director of Health Information Management, All Care Health Center, 902 South 6th Street, Council Bluffs IA 51501. ACHC does not require completion of this form as a condition of evaluation or treatment. However, when the requested evaluation or treatment is solely for the purpose of creating a medical report for a third party, if authorization to release the information to that third party is not provided, it may result in the cancellation of those services. I understand that the information may be released electronically, and will not include information in the following categories, unless I specifically request the release: substance use, mental health, HIV-related information, genetic tests/info. Please check any category you request to be released. settings Genetic tests/information refers to genetic testing to screen for possible future health issues, does not refer to testing to diagnose or treat current health conditions. Substance Use Mental Health HIV-Related Information Genetic Tests/Information If you would like the agreement cancelled early what is the specific date you would like it cancelled. settings This agreement will expire one year from the date of signature, or as indicated unless cancelled by the patient/guardian. * settings Clear Todays Date * settings Complete Mailing Address/Street/P.O. Box settings City, State, Zip Code settings Relationship, if Not the Patient settings Witness Signature settings Clear Date Signed settings Patient Signature * settings Clear Date Signed * settings Submit CONSENT FOR RELEASE OF INFORMATION Click Submit to finish. arrow_back Back Submit Call 712-325-1990 to make an appointment.
