ROI How do I become a patient? ¿Cómo me convierto en paciente? Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastDOB *Social Security Number *I hereby authorize the staff of CHCNRV at: *Christiansburg: 215 Roanoke | Street Christiansburg, VA 24073 | 540.381.0820Giles:219 South Buchanan Street | Pearisburg, VA 24134 | 540.921.3502Dublin: 5826 Ruebush Road | Dublin, VA 24084 | 540.585.1310to: *ProvideRequest Written or Verbal Information From or To: Name / Title *Fax numberMailing address (if applicable) Dates of information release *AllFromDates for release of records *The nature of information to be disclosed: *Progress notes Treatment plans AssessmentsMedical information Treatment summary Psychiatric notes Drug test resultsDiagnostic evaluations Other information that may be released: The purpose of this disclosure is: *Treatment planning Provide case management Report on progress Determine disabilityDetermine recommendations for further treatment OtherIf "Other" what is the purpose of disclosure? *As the person signing this consent, I understand that I am giving my permission to the above-named provider or other named third party for disclosure of confidential health care records. I further understand that CHCNRV cannot condition the provision of treatment to me on my signing of this authorization. This consent is valid unless revoked by me prior to the expiration date, but not retroactive to information already released. A copy of this consent and a notation concerning the persons or agencies to which disclosure was made shall be included with my original records. The person who receives the records to which this consent pertains may not re-disclose them to anyone else without my separate written consent unless the recipient is a provider who makes a disclosure permitted by law. There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipient and, therefore, no longer protected by the provisions of the HIPAA Privacy Rule. This consent extends to information placed in my record after my consent was given but before it expires. I also understand that my records are protected under State and Federal substance abuse confidentiality laws and regulations and cannot be disclosed without my written consent unless otherwise provided for in the laws and regulations. I agree that a photocopy of this form is as valid as the original. NOTE WHERE INFORMATION ACCOMPANIES THIS DISCLOSURE FORM: THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS PROTECTED BY FEDERAL CONFIDENTIALITY RULES (42CFR PART 2). THE FEDERAL RULES PROHIBIT YOU FROM MAKING ANY FURTHER DISCLOSURE OF THIS INFORMATION UNLESS FURTHER DISCLOSURE IS EXPRESSLY PERMITTED BY THE WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS OR AS OTHERWISE 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 RULE RESTRICTS ANY USE OF THE INFORMATION TO CRIMINALLY INVESTIGATE OR PROSECUTE ANY ALCOHOL OR DRUG ABUSE CLIENT. Consent timeframe: *This consent is good for one year from the effective date. This consent is only valid until date below (less than 12 months)If less than one year, put date here *Signature *Clear SignatureClient, parent, guardian or legally authorized representativeDate *Witness / Title or Credentials Clear SignatureDateYou may revoke this authorization at any time by signing and dating a written request.Submit
