CIJ Test | Affinity Clinical Se

Affinity Clinical Services, PLLC

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION CRIMINAL JUSTICE SYSTEM REFERRAL 42 CFR Part 2 and HIPAA

Full Name

(Client's Name)

authorize Affinity Clinical Services, PLL 5624 Executive Center drive #105, Charlotte, NC 28212 to obtain or release and exchange information specified below (including paper, oral, and facsimile interchange) with the following parties:

NC DMV

NC Division of MH/DD/SAS

Short answer

Name of Criminal Defense Attorney

Short answer

Name of appropriate court

Short answer

Name of prosecuting Dristric Attorney

Short answer

Other

the following information:

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my diagnosis, urinalysis results, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program, prognosis, and/or

E508, Assessment, Driving Record, Blood alcohol Concentration reading or copy of the DWI police ticket[describe how much/what kind of information may be disclosed, including & explicit description of what substance use disorder information may be disclosed; as limited as possible] for the purpose of Coordinating substance abuse and/or DWI care. [describe the purpose of the disclosure; as specific as possible]

I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Client Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:

Short answer

Date

or One year from the date signed below.

Short answer

Date

[describe date/event/ condition upon which consent will expire; must be no longer than reasonably necessary to serve the purpose of this consent]

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.