authorize Bloom Recovery Network LLC to disclose Registration letter, attendance of lack of attendance, participation (understanding of objectives, behavior/response), cooperation with the DIP program rules and expectations, Program Completion Report, Certificate of Completion
Please email email@example.com if the Authorization for Disclosure of Confidential SUD Records included in this registration process does not accurately reflect the following:
-How much and what kind of information you want disclosed, -The purpose for that disclosure -The date, event or condition upon which the consent will expire,-OR disclosure to any other person or agency beyond your sentencing court (such as an Attorney, PO, other referring agency or individual)
This Authorization for Disclosure form is specific to your sentencing court and disclosure of the information we are required (or may be requested) to provide.
This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see 42 CFR 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at 42 CFR 2.12(c)(5) and 42 CFR 2.65.
I understand that I may be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or healthcare operations, if peremitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
I have been provided a copy of this form.