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 Name *

Date of Birth *

Recipient / Source

Organization or Individual

Address / Phone

Purpose of Disclosure

Purpose (check one or more)

Continuity of CareHousing CoordinationLegal ComplianceBillingOther

If Other, specify

Type of Information

Information to release

AttendanceTreatment participationDrug screeningHousing complianceOther

If Other, specify

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.

Signatures

Resident Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Resident Printed Name *

Date *

Staff Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Staff 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.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.

Kura Solution

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