Note: Due to risks associated with faxing confidential health information, VBHCS limits faxing to special circumstances (i.e. client care emergencies, sharing authorized information with other healthcare providers/agencies). I authorize VBHCS to release only specified client health information by facsimile (fax) as indicated.
This information I authorize for release may include information that could be considered information about communicable or venereal disease which may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS). I understand that I may revoke this consent at any time. However, I also understand that any release which has been made prior to my revocation and which was made on the basis of this authorization shall not constitute a breach of my Right of Confidentiality. I understand that my records are protected under the federal regulations 42, CFR Part 2, HIPAA and TCA 33 and cannot be disclosed without my written consent unless otherwise provided for in these regulations. I understand that information used or disclosed in accordance with this authorization may no longer be protected by federal law and could be re-disclosed. However, if the information contains reference to diagnosis, history, treatment or rehabilitation for drug and/or alcohol abuse and substance abuse, then federal law may prohibit the receiving party from re-disclosure without my consent. I understand that treatment, payment, enrollment, or eligibility benefits will not be conditioned on signing this authorization, and that there are no consequences to me if I refuse to sign this authorization. This authorization is given freely, voluntarily and without coercion. This authorization shall expire automatically in twelve (12) months if no date is indicated below.