Confidential Agreement Form

 

Consent for Release of Confidential Information

 

Name _____________________________________S.S. #_________-_______-_________D.O.B. ________________

 

I, _______________________________________________________________authorize:

 

Name of program making disclosure: Greenville Hospital System                                                                       

To disclose to: Heart of Hannah/Narvis Hart – Director

The following information: All medical records concerning past or present treatment.

Purpose of disclosure is: Per Client request

The information will be released in the following form: (  ) written (  ) verbal    

(  ) audio (  ) electronic fax (  )e-mail (  ) Other _______(  ) any of the above

 

I understand that my records are protected under federal regulations governing Confidentially of Alcohol and Drug Patient Records, 42 CFR, Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except this consent expires one year from my intake at Heart of Hannah.      

 

            

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Signature                                                                                                      Date                                            

 

I HAVE BEEN ADVISED BY HEART OF HANNAH NOT TO EAT ANYTHING THAT HAS POPPY SEED IN OR ON IT DUE TO THE FACT I WILL TEST POSITIVE FOR OPIATES.

IF I TEST POSITIVE IT COULD BE AN AUTOMATIC DISCHARGE FROM THIS PROGRAM.

 

Also, I have been advised to never drink energy drinks on week-ends, work or at a convenient store.

 

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Signature                                                                                                     Date

 

Please Note: We are committed to assisting all clients in their recovery process. In return we expect you to be responsible for your part in this process; your behavior while at H.O.H. may determine future admission or visit to this facility.

 

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Signature                                                                  Date

 

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Staff Approval                                                         Date

 

Authorization for Emergency Medical Treatment

 

I, _________________________________as a current client/resident, do authorize Heart of Hannah to seek medical attention for me in case of illness or injury.

I authorize Heart of Hannah to contact a Physician and/or medical facility to arrange for immediate emergency treatment.

I hereby authorize the Physician and/or medical facility to administer any emergency medical treatment they deem necessary to ensure my health.

I agree that Heart of Hannah can in no way be held liable in case of illness or an injury to me.

I understand and agree that Heart of Hannah is in no way responsible for payment of said medical services administered.

 

Signature: _______________________________________Intake Date: ____________________________

 

Medical Alert information: (allergies, etc.) _______________________________________________________________________________________________________

Medication currently taken and for what reason:

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