Release of Information

This form requires a witness signature and is not valid or usable without a witness signature. A witness can be a roommate, parent, partner, significant other, etc — or anyone else in the home above the age 18. Alternatively, your therapist can sign the form while in the presence of the client.

Release of Information
Authorization to Use and Disclose Confidential Protected Health Information

Regarding (Client Name)*

Date of Birth (Client Date of Birth*

I authorize InnerSourced Solutions to release my entire chart and file and the nature of the information to be disclosed includes any and all medical records, mental health records, and communication and/or summary of the treatment of the patient named above to:

Name of Program / Person Authorized to Disclose / Receive / Exchange Information *

Company Individual works for

Purpose of Disclosure - Select one

Information to be Disclosed:*

Amount of Information to be Disclosed

I understand that I may revoke this consent at any time, and that I have the right to inspect and copy the information to be disclosed. This consent is valid until: *

It has been explained to me that my refusal to consent to this release of authorization will result in the following: 

This form is not valid without a witness

​I understand I can revoke this permission in writing or verbally at any time except to the extent that the program that is to make the disclosure has already taken action in reliance on it. The program cannot make signing this consent form a condition of treatment unless my treatment is required to satisfy an order from a court, another criminal justice agency, or is to be disclosed to a third party for payment, in which cases I may be denied treatment if I do not sign this consent form (per HIPAA, 1996).

NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure:  This information has been disclosed to you from records protected by federal confidentiality rules. 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 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 information to criminally investigate or prosecute any alcohol or drug abuse client.  Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164.  These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.

NOTICE TO RECEIVING AGENCY/ PERSON: Under the provisions of the Illinois Mental Health and Development Disabilities Confidentiality Act, you may not redisclose any of this information unless the person who consented to this disclosure specifically consents to such a redisclosure. Under the Federal Act of July 1, 1975, Confidentiality of Alcohol and Drug Abuse Patient Records, no such records, nor information from such records may be further disclosed without specific authorization of such redisclosure.