Admission Packet Forms (Fletcher Group)

I, the undersigned, authorize PursueCare and its affiliated entities to disclose the following records that I understand may contain information concerning psychiatric, psychological, drug or alcohol use, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions.

I understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire upon my discharge from PursueCare.

I understand that by signing below I am giving my consent to disclose my information as outlined above. I understand that I will not be denied services if I refuse to consent to disclosure, but denying consent related to treatment, payment, or health care operations may disrupt or otherwise affect my ability to pay for or receive services.

Prohibition on Re-disclosure This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

I, the undersigned, authorize PursueCare and its affiliated entities to disclose the following records that I understand may contain information concerning psychiatric, psychological, drug or alcohol use, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions.

I understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire upon my discharge from PursueCare.

I understand that by signing below I am giving my consent to disclose my information as outlined above. I understand that I will not be denied services if I refuse to consent to disclosure, but denying consent related to treatment, payment, or health care operations may disrupt or otherwise affect my ability to pay for or receive services.

Prohibition on Re-disclosure This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

I understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire upon my discharge from PursueCare.

I understand that by signing below I am giving my consent to disclose my information as outlined above. I understand that I will not be denied services if I refuse to consent to disclosure, but denying consent related to treatment, payment, or health care operations may disrupt or otherwise affect my ability to pay for or receive services.

Prohibition on Re-disclosure This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

I understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire upon my discharge from PursueCare.

I understand that by signing below I am giving my consent to disclose my information as outlined above. I understand that I will not be denied services if I refuse to consent to disclosure, but denying consent related to treatment, payment, or health care operations may disrupt or otherwise affect my ability to pay for or receive services.

Prohibition on Re-disclosure This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

I understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire upon my discharge from PursueCare.

I understand that by signing below I am giving my consent to disclose my information as outlined above. I understand that I will not be denied services if I refuse to consent to disclosure, but denying consent related to treatment, payment, or health care operations may disrupt or otherwise affect my ability to pay for or receive services.

Prohibition on Re-disclosure This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

This consent to release information is valid for disclosure to: Dr. Tonika East Director of the Lifelong Learning Branch, Office of Adult Education, 500 Mero Street, #5SC WK87, Frankfort, KY 40601.

I understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire upon my discharge from PursueCare.

I understand that by signing below I am giving my consent to disclose my information as outlined above. I understand that I will not be denied services if I refuse to consent to disclosure, but denying consent related to treatment, payment, or health care operations may disrupt or otherwise affect my ability to pay for or receive services.

Prohibition on Re-disclosure This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

This consent to release information is valid for disclosure to: Fletcher Group, Inc. 601 Meyers Baker Road, STE 238, London, KY 40741.

I understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire upon my discharge from PursueCare.

I understand that by signing below I am giving my consent to disclose my information as outlined above. I understand that I will not be denied services if I refuse to consent to disclosure, but denying consent related to treatment, payment, or health care operations may disrupt or otherwise affect my ability to pay for or receive services.

Prohibition on Re-disclosure This information has been disclosed from records protected by Federal Confidentiality rules (42 CFR part 2). The Federal rules prohibit making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.