Release of Drug and Alcohol Related Information. I understand that under Federal and Ohio law the disclosure of medical records related to the diagnosis, prognosis, or treatment of alcoholism, alcohol abuse, or drug abuse require a separate written authorization that includes the following: Name of the program making the disclosure; name of the individual or the organization to receive the disclosure; name of the patient; the purpose of the disclosure; the type and amount of information to be disclosed; the signature of the patient or person authorized to give consent; the date the patient or other authorized person signed the form; a statement that the consent is subject to revocation at any time except to the extent the program or person who is to make the disclosure has already acted in reliance on it; and the date, event or condition upon which the consent will expire, unless revoked before that specified time. I further understand that this information will not be released without the separate written authorization described above.
Release of Drug and Alcohol Related Information. I understand that under Federal and Ohio law the disclosure of medical records related to the diagnosis, prognosis, or treatment of alcoholism, alcohol abuse, or drug abuse require a separate wriﹷen authorizaﳳon that includes the following: Name of the program making the disclosure; name of the individual or the organizaﳳon to receive the disclosure; name of the paﳳent; the purpose of the disclosure; the type and amount of informaﳳon to be disclosed; the signature of the paﳳent or person authorized to give consent; the date the paﳳent or other authorized person signed the form; a statement that the consent is subject to revocaﳳon at any ﳳme except to the extent the program or person who is to make the disclosure has already acted in reliance on it; and the date, event or condiﳳon upon which the consent will expire, unless revoked before that specified ﳳme. I further understand that this informaﳳon will not be released without the separate wriﹷen authorizaﳳon described above.
