Client's Date of Birth

I authorize the mutual exchange of confidential information between Glacier Health and Development Center and the person(s) and/or agencies that are listed and described below.

Yes

Person or Agency Releasing Information to Glacier Health (i.e. Name of psychiatrist, primary care doctor, school, or family member. Please use the name of the organization if the contact is affiliate with an office or facility):

Method of Release Allowed (please select all):

Telephone Contact Telephone Contact In Person Delivery and/or Communication Email Communication

Phone Number of Person or Organization:

Fax Number for Person or Organization:

Email Address for Person or Organization

The purpose of this authorization includes (please select all)

Coordination of Care Treatment and/or Service Planning

Information to be released includes

Specially authroized release of information:

I authorize release of information to the extent that my record contains information pertaining to the identity, prognosis, or treatment for alcohol or drug abuse. I specifically authorize release of information to the extent that my record contains information pertaining to the identity, prognosis, or treatment for AIDS, ARC or HIV. I specifically authorize release of information to the extent that my record contains information pertaining to the results of genetic testing.

Specially authorized releases of information: I authorize release of information to the extent that my record contains information pertaining to the identity, prognosis, or treatment for alcohol or drug abuse. I specifically authorize release of information to the extent that my record contains information pertaining to the identity, prognosis, or treatment for AIDS, ARC or HIV. Ispecifically authorize release of information to the extent that my record contains information pertaining to the results of genetic testing.

IMPORTANT INFORMATION ABOUT THE RELEASE OF YOUR HEALTH INFORMATION

Health Information includes information collected or created by the provider and/or provider facility. Health information may include information that has been received by the provider and/or provider organization from another person, provider, or organization. Health information may relate to your past, present, or future health and or services. Health information may also include details on the provision of your care or payment for services. Glacier Health and Development Center cannot guarantee that the recipient of protected information will not redisclose information upon receipt. This authorization may be revoked at any time, except that the revocation will not have any effect on disclosures made as permitted by this authorization before the notice of revocation is received. You may refuse to sign this authorization if you wish. Refusal to sign this authorization will not affect your ability to obtain services through Glacier Health and Development Center, except if you are (i) being transferred for the purpose of continuing services (ii) receiving services for the sole purpose of creating information for disclosure to a third party (ii) involved in some other matter which requires the sharing of certain information to render support. If either of these exceptions apply, your refusal to sign an authorization may result in non-admission or a dismissal from services.

Unless revoked, this authorization will expire on

I have read the "Important Information" section above and I have had an opportunity to discuss the use of this disclosure with a knowledgeable staff person. As such, I understand and accept the terms of this authorization. I agree that copies of this form will be as valid as originals, and that I may revoke authorization any time:

Client/Parent/Guardian Signature