Internet Addiction Recovery Program APPLICATION ... - HEAL

Internet Addiction Recovery Program
RELEASE OF INFORMATION
I hereby authorize that health care information for:
LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME PERSONAL ID#(PID) *SOCIAL SECURITY NUMBER
BE MUTUALLY EXCHANGED between reSTART Internet Addiction Recovery program and
LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME RELATIONSHIP TO APPLICANT
PERMANENT ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NUMBER
LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME RELATIONSHIP TO APPLICANT
PERMANENT ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NUMBER
LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME RELATIONSHIP TO APPLICANT
PERMANENT ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NUMBER
For the purpose of:
_____ Diagnosis and treatment
_____ Psychological evaluation
_____ Coordination of care/Verbal updates
_____ Other: _____________________
I understand:
(1) That my records are protected under Federal and State statutes and cannot be disclosed without my written consent unless
otherwise provided for in the statutes.
(2) That I may revoke this consent, in writing, at any time except to the extent that action has already been taken relative to it.
(3) That my specific permission is required to release any health care information regarding testing, diagnosis or treatment for HIV
(AIDS virus), communicable/sexually transmitted diseases, psychiatric disorders, mental health, drug or alcohol treatment.
(4) That a photocopy of this consent shall have the same effect as the original.
________________________________ _____________ ______________________________ ___________
(Signature of Applicant) (Date) (If Minor, Signature of Guardian) (Date)
________________________________ _____________
(Signature of Parent or Guardian) (Date)
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reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189
restart@netaddictionrecovery.com | www.netaddictionrecovery.com