Authorization to Release Information Are you requesting to receive a copy of your own records as a client of Northpoint, or are you requesting that a copy of your records be sent to another person or entity? I am requesting to receive a copy of my own records I am requesting that a copy of my records to be sent to another person or entity Name of patient requesting disclosure of medical records(Required) First Last Name at Time of Treatment (if different than above):Patient Date of Birth(Required) MM slash DD slash YYYY Last 4 digits of SSN(Required)PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I am requesting records for:(Required)Please select from the dropdownResidential TreatmentOutpatient TreatmentWhich facility are you requesting records from?(Required) Northpoint Recovery (Meridian, ID) Northpoint Washington (Edmonds, WA) Northpoint Colorado (Loveland, CO) Northpoint Nebraska (Omaha, NE) Which facility are you requesting records from?(Required) Ashwood Recovery (Boise, ID) Northpoint Seattle (Seattle, WA) Northpoint Loveland (Loveland, CO) Northpoint Omaha (Omaha, NE) Information to be disclosed in release of records (please check all that apply)(Required) Presence in treatment Progress in treatment Treatment plans Psychological assessment Psychiatric history and assessment Results of physical exam Medical history/current status Biopsychosocial assessment Laboratory test results Employment information Legal status Family information Aftercare recommendations Discharge summary Financial Other (please specify in notes) All of my medical records maintained by Northpoint in the designated record set. Message:I would like my records sent via:(Required)Please select from the dropdown the format in which you would like records delivered.MailFaxEmailAddress you would like records sent:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Fax number where you would like records sent:(Required)mail address where you would like records sent:(Required) Signature(Required)I, the undersigned individual below, declare under penalty of perjury under the laws of the state in which I am located that I am the Patient named above, and hereby request my medical records as set forth in this Patient Request to Access Medical Records form. Check here to indicate that you have read and agree to the terms of this Patient Request to Access Medical Records form on the date that you click “Submit” below.Name of patient requesting disclosure of medical records(Required) First Last Email address of patient requesting disclosure of medical records(Required) Patient Date of Birth(Required) MM slash DD slash YYYY Last 4 digits of SSN(Required)I am requesting records for:(Required)Please select from the dropdownResidential TreatmentOutpatient TreatmentWhich facility are you requesting records from?(Required) Northpoint Recovery (Meridian, ID) Northpoint Washington (Edmonds, WA) Northpoint Colorado (Loveland, CO) Northpoint Nebraska (Omaha, NE) Which facility are you requesting records from?(Required) Ashwood Recovery (Boise, ID) Northpoint Seattle (Seattle, WA) Northpoint Loveland (Loveland, CO) Northpoint Omaha (Omaha, NE) Name of person or organization you would like to send records to(Required)I would like my records sent via:(Required)Please select from the dropdown the format in which you would like records delivered.MailFaxEmailAddress of the organization/person you would like records sent:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Fax number of organization/person you would like records sent:(Required)Email address or organization/person you would like records sent:(Required) Phone number of organization/person to receive medical records(Required)Information to be disclosed in release of records (please check all that apply)(Required) Presence in treatment Progress in treatment Treatment plans Psychological assessment Psychiatric history and assessment Results of physical exam Medical history/current status Biopsychosocial assessment Laboratory test results Employment information Legal status Family information Aftercare recommendations Discharge summary Financial Other (please specify in notes) Message:Purpose for the disclosure of medical records (please check all that apply)(Required) Treatment/Continuing medical care Personal use Billing or claims Insurance Legal purposes Disability determination School Employment Other (please specify in notes) Message:Sensitive Information(Required) Check here to indicate your understanding that your medical records to be disclosed under this consent may include information concerning your psychiatric, psychological, drug and alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS} and/or related conditions.Additional Information(Required)By signing below, you certify your understanding that your medical records to be disclosed under this Authorization are protected under Federal Confidentiality regulations (42 CFR Part 2}. Published August 10. 1987, and the Heath Insurance Portability and Accountability Act of 1996 (P.L. 104-191 ), 42 U.S.C. Section 1320d, et. Seq, and cannot be disclosed without your written consent unless otherwise provided for in the regulations. Unless sooner revoked, this Authorization expires in 12 months or upon termination of your treatment at Northpoint Recovery, whichever is later; provided that the Authorization shall expire in 12 months to the extent it authorizes disclosure of medical records to a financial institution or to my employer for purposes other than payment. By signing below, you certify your understanding that you might be denied services if you refuse to authorize disclosure of your medical records for purposes of treatment, payment, or health care operations, if permitted by state law. You will not be denied services if you refuse to authorize the disclosure of your medical records for other purposes. Unless you have requested in writing that disclosure be made in a certain format, we reserve the right to disclose medical records as permitted by this Authorization in any manner we deem to be appropriate and consistent with applicable law, including but not limited to verbally, in paper format, or electronically. You understand that medical records used or disclosed pursuant to this Authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Each disclosure of medical records subject to 42 CFR Part 2 made by Northpoint with your written consent will be accompanied by the following statement: "42 CFR Part 2 prohibits unauthorized disclosure of these records." You understand that you have a right to revoke this Authorization, in writing, at any time by sending written notification to medicalrecords@northpointrecovery.com. You further understand that a revocation of the Authorization is not effective to the extent that action has been taken in reliance on this Authorization. You may request a copy of this Authorization for your records by emailing medicalrecords@northpointrecovery.com. Check here to indicate that you have read and agree to the terms of this Authorization.Signature(Required)I certify under penalty of perjury pursuant to the law of the state in which I am located that I am the patient named above. I hereby hold harmless and release and forever discharge Northpoint and its affiliated entities from all claims, demands, and causes of action which I, my heirs, guardians, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of reliance on this Authorization. I consent to receive a copy of this Authorization, and communicate with Northpoint and its affiliated entities, via unencrypted email at the email address provided above. I acknowledge that unencrypted email messages could be intercepted by unauthorized third parties or read by other people who have access to email account. With knowledge of these risks, I consent to the receipt of unencrypted email messages. Check here to indicate that you have read and agree to the terms of this Patient Request to Access Medical Records form on the date that you click “Submit” below.Optin By submitting this form, I agree to receive communications, including texts, calls, and/or emails, regarding services, appointments, alumni resources, and news from Northpoint brands. Δ
