Don Sheeley, MD, ABIM, Addiction Medicine and Psychotherapy,
ACT Smart New York, 120 West Avenue, Suite 203, Saratoga Springs, NY, 12866, donsheeley99@gmail.com,
phone 518 813 8971, fax 518 444 0854.
Authorization for Release of Health Information Pursuant to HIPAA
I request that my health information regarding my evaluation, care and treatment be released. I understand that this authorization will include disclosure of information relating to ALCOHOL AND DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, AND CONFIDENTIAL HIV INFORMATION IF I SIGN BELOW. By signing below I agree to have my information released to the person below, and their office, and legal representatives.
The recipient is prohibited from re-disclosure of such information without my authorization unless permitted by law. I have the right to revoke this authorization by writing to the practitioner’s office above; this does not apply to information already released.
My signing this form is voluntary, and my treatment is not contingent upon my signing this form.
Information might legally be re-disclosed by the recipient and this re- disclosure may not be protected by law.
Office Releasing Information:
Don Sheeley, MD, ACT Smart New York, 120 West Ave, Suite 203, Saratoga Springs, NY 12866,
phone 518 813 8971, fax 518 444 0854.
(Recipient): NAME AND ADDRESS TO WHOM MY CONFIDENTIAL INFORMATION SHOULD BE SENT: ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
INFORMATION TO BE SENT WILL INCLUDE A CLINICAL SUMMARY INCLUDING ALCOHOL AND DRUG TREATMENT, UNLESS ADDITIONAL INFORMATION IS LISTED HEREIN:
[DO NOT SHARE THIS INFORMATION _____________________________________________________________ ___________________________________________________________________________________________]
BY SIGNING BELOW I AGREE TO DISCLOSURE OF ALL OF MY INFORMATION except psychotherapy notes WITH THE RECIPIENT named above FOR A PERIOD OF 5 YEARS FROM THE START OF MY TREATMENT IN THIS OFFICE:
Name, Printed ______________________________
Patient Signature ___________________________ Date Signed _____________________________________
Witness Signature __________________________ Date Signed ______________________________________