Record Request Form

Patient Record Request Form
Please select the statement that best describes you:*

I am a patient looking to request my records for myselfI am a patient looking to request my records be sent to someone else (provider, organization, justice system, etc.)I am a third-party requesting records for a patient

Release of Information (ROI)
A valid Release of Information (ROI) is required for all record requests. Please select the statement that is most applicable:*

There is a valid ROI on file already. I have a copy of it to attach.There is a valid ROI on file already, but I do not have a copy of it.There is an ROI that is not already on file, and I have a copy of it to attach.I do not have an ROI on file, or don't know if I have an ROI on file.
Please upload a copy of the ROI you have:*

Cancelof

Consent for the Release of Information under 42 C.F.R. Part 2 Confidentiality of Substance Use Disorder Patient Records
This Record Request Form is valid for one-time use.

IMPORTANT: 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 §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 §§2.12(c)(5) and 2.65.
Is the patient involved with the court system (i.e. Civil, Criminal, Probation, Child Protective Services)?*

YesNo

FOR JUSTICE SYSTEM PATIENTS ONLY

Note: Contact information for at least one of these individuals is required.
Judge

Please provide the following information if applicable.
Judge First and Last Name
Judge First and Last Name
Judge Contact Phone Number, Fax Number, Email, or N/A
Judge Contact Phone Number, Fax Number, Email, or N/A
Probation/Parole Authority (Office/Dept)

Please provide the following information if applicable.
Probation/Parole Authority (Office/Dept)
Probation or Parole Authority Name
Probation Contact Phone Number, Fax Number, Email, or N/A
Probation Contact Phone Number, Fax Number, Email, or N/A
Defense Attorney

Please provide the following information if applicable.
Defense Attorney First and Last Name
Defense Attorney First and Last Name
Defense Attorney Contact Phone Number, Fax Number, Email, or N/A
Defense Attorney Contact Phone Number, Fax Number, Email, or N/A
Prosecuting Attorney

Please provide the following information if applicable.
Prosecuting Attorney First and Last Name
Prosecuting Attorney First and Last Name
Prosecuting Attorney Contact Phone Number, Fax Number, Email, or N/A
Prosecuting Attorney Contact Phone Number, Fax Number, Email, or N/A
Child Protective Services

Please provide the following information if it's applicable to you.
Child Protective Services Name
Child Protective Services Name
Child Protective Services Contact Phone Number, Fax Number, Email, or N/A
Child Protective Services Contact Phone Number, Fax Number, Email, or N/A
Other Parties

If there is any other relevant party, please provide the following information.
Other Person or Organization Name
Person or Organization Name
Other Person or Organization Contact Phone Number, Fax Number, Email, or N/A
Other Person or Organization Contact Phone Number, Fax Number, Email, or N/A

Purpose of disclosure:*

Continuity of CareCoordinating TreatmentLegalPayment/BenefitsOther
I understand that my substance use disorder patient records are protected under federal regulations 42 C.F.R. Part2 Confidentiality of Substance Use Disorder Patient Records and cannot be disclosed without my written consent. I do not need to sign this form to obtain treatment. I may revoke this consent in writing at any time. I understand that the revocation will not be effective retroactively for information disclosures that have already occurred. I understand that generally BrightView may not condition my treatment on whether I sign a consent form, but in certain limited circumstances, I may be denied treatment if I do not sign a consent form.*

Yes, I understand.
If not previously revoked, this consent will terminate:*

In one year from the date of signature OR 90 days after discharge (whichever comes first); ORUpon a specific dateUpon a specific event or condition
Revoke consent on:

MonthDayYear
Date
Event or condition in which this consent will terminate:*
Specific date, event , or condition in which this consent will terminate:
Signature of patient*

Clear
Date signed

MonthDayYear
Date
Hour MinutesAM/PM Option
Patient First and Last Name*
Type your first and last name
Personal Representative's Signature*

Clear
Date signed:

MonthDayYear
Date
Hour MinutesAM/PM Option
Full Name of Personal Representative*
Legal Authority of Personal Representative*

Notice of Federal Requirements Regarding the Confidentiality of Substance Use Disorder Patient Information
The confidentiality of substance use disorder patient records maintained by this program is protected by federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless:

1.The patient consents in writing; or

2.The disclosure is allowed by a court order accompanied by a subpoena; or

3.The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation; or

4.The patient commits or threatens to commit a crime either at the program or against any person who works for the program.

Violation of federal law and regulations by a program is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs.

Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

The releases of information will remain active and valid for one year from the date of signature OR until 90 days after discharge (whichever comes first) OR until a specific date, event, or condition as listed on the form. There are two ways to revoke a release of information: Come in to the BrightView facility where you were scheduled to receive treatment and sign the revocation, or fax in a written statement with your name, signature, date and release(s) you would like to be revoked.

(See U.S.C. §290dd-2 for federal law and 42 C.F.R. Part 2 for federal regulations governing Confidentiality of Substance Use Disorder Patient Records

BrightView, LLC | 4600 Montgomery Rd., Cincinnati, OH 45212 | Phone: 833.510.HELP (4357) | Fax: 833.510.4329
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Patient Record Request Form

Release of Information (ROI)

Patient Record Request Form

Consent for the Release of Information under 42 C.F.R. Part 2 Confidentiality of Substance Use Disorder Patient Records

FOR JUSTICE SYSTEM PATIENTS ONLY

Judge

Probation/Parole Authority (Office/Dept)

Defense Attorney

Prosecuting Attorney

Child Protective Services

Other Parties

Notice of Federal Requirements Regarding the Confidentiality of Substance Use Disorder Patient Information