Release of Information (42 CFR Part 2)

Authorization for release of confidential information.

Kura Solution

Appendix E — Release of Information (42 CFR Part 2)

Authorization for release of confidential information.

Resident

Resident First Name *

Resident Last Name *

Date of Birth *

Recipient / Source

Organization or Individual *

Address / Phone *

Purpose of Disclosure

Purpose (check one or more) *

Continuity of CareHousing CoordinationLegal ComplianceBillingOther

Type of Information

Information to release *

AttendanceTreatment participationDrug screeningHousing complianceOther

This consent expires on *

I understand I may revoke this consent at any time in writing. Redisclosure is prohibited without my consent. My information is protected under 42 CFR Part 2.

Resident Signature

Resident Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Resident Printed Name *

Date *

Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

Your submission is stored securely — you can download a signed PDF copy any time from My Submissions. Records protected under 42 CFR Part 2 & HIPAA.

Kura Solution

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(260) 366-9083
support@kurasolution.com
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