Georgia Department of Human Resources REGION 4 ‘Name of individual/Consumer/PallenvApplicant Intake & Evaluation ~ P.O, Box 1378 Date oF bith ‘Social Security Number 400'S. Pinetree BV. | ae aval ABLE: . Thomasville, GA 31799 — TD Number Used by TD Number Used by Reatiesting Agency Releasing Agency AUTHORIZATION FOR RELEASE OF INFORMATION eee DHR Region 4 Intake & Evaluation (Name of Person or Agency Requesting Information) P.O. Box 1378 400 S. Pinetree Blvd. Thomasvile, Ga. $1799 Phone: 1-877-683-8557 Fax (220) 227.2918, Tadaress) To - 1 Release to (Name of Person or Agency Holding the Information) Obtain from: Tedaressy the following type(s) of information from my records (to include alcohol, drug, HIV, and any specific portion thereat) Medical, psychiatric or psychological assessments, progress notes, and other pertinent information necessary for continuing care forthe puese of ro determine elglty & ongoing series for MHODAD senvces. do NOT authorize the release of alcohol and drug information. nals | do NOT authorize the release of HIV andior treatment for AIDS Information. inital | understand that the federal Privacy Rule ("HIPAA") does not protect the privacy of information if r-disclosed, and therefore request that al information obtained from this person or agency be held strictly confidential and not be further released by the recipient. | further understand that my eligibility for benefits, treatment or payment is not conditioned upon ‘my provision ofthis authorization. | intend this document to be @ valid authorization conforming to all quirements of the Privacy Rule and understand that my authorization will remain in effect for: (CHECK ONE) Cininety (90) days unless | specify an earlier expiration date here: Cone (1) year. (Date) ithe period necessary to complete all transactions on matters related to services provided to me. understand that unless otherwise limited by state or federal regulation; and except to the extent that action has been taken based upon it, may withdraw this authorization at any time, (Gignature of IndiviauaConsumer ‘Gignature of Parent or other legally Authorized | (Cate) (Date) ‘Patient/Applicent) Representative, where applicable) (Gignaiure of Witness Tile or Relationship (Gignature of Wines Tite or Relationship (ate) (Bate) to Individual) te Individual) | “Two witnesses required if signed with an “x"*" USE THIS SPACE ONLY IF AUTHORIZATION IS WITHDRAWN’ (Date tis authorization is revoked by individual) (Gignature of Individualfegally Authorized Representative) (Rev. 4/2004) Form $459 (Rev. 4/14/2004) Previous versions are obsolete and should nat be used. |