PORTNEUF VALLEY FAMILY CENTER INC.

Pocatello Office: Blackfoot Office: Soda Springs Office:

444 Hospital Way, Ste. 477 1495 Parkway Dr., Ste. C 15 West Center, Ste. 2

Pocatello, Idaho 83201 Blackfoot, Idaho 83221 Soda Springs, Idaho 83230

Phone: 233-7832 Fax: 233-7835 Phone: 785-7832 Fax: 785-7833 Phone: 547-4470 Fax: 547-4640

Authorization to Release Information

I, the undersigned hereby authorize and designate: ______

to release information to: Portneuf Valley Family Center, Inc. for the following individual:

______

Patient/Consumer Date of Birth Social Security Number

Information is to be used for the following purpose: ______and this purpose only.

This authorization includes all or any part of records and/or information designated below, including treatment for physical and/or mental health, developmental disability treatment, or substance abuse.

Information to be released includes:

_____Admission/Intake Notes _____ Individualized Treatment Plan _____Comprehensive Diagnostic Assessment _____ Treatment Notes _____Psychological History _____ Physician Progress Notes

_____DSM IV-TR(DSM - V) Diagnosis Information _____ Physician’s Physical Exam & History _____Psychological Testing Results _____ Discharge Information

_____Medication History & Records _____ School Testing Information

_____CAFAS/PECFAS _____ School IEP

_____ Substance Use Records _____Other:______

This consent may be revoked at any time, other than if action has already been taken. This authorization will expire one year from the date this authorization is signed unless specified here (insert date): ______

→______

Signature (Guardian/Parent Signature for children) Date

______

Staff or Witness Signature Date

Portneuf Valley Family Center, Inc. will not make any further disclosure of information without the specific, written consent of the person (or legal guardian) to whom the information pertains under federal law. A general authorization for the release of further information is not sufficient for this purpose.

Please send to the following office (Circle): Pocatello Blackfoot Soda Springs (See contact information above) <

______

Revocation of Authorization: I hereby revoke the authorization for the consent listed above:
______
Signature Date:

09/30/2016 – Revised Authorization to Release Information. Property of Portneuf Valley Family Center, Inc.© Unauthorized copying, changing, and/or distribution of this document is strictly prohibited.