Pillar Release of Information Form

Pillar

Authorization for Release/Exchange of Information Form
By signing this form I authorize Pillar to release my medical records with specified party below.
Signing below grants permission to : Pillar
to release/exchange the following written and verbal information concerning: First Name* Last Name* . Date of Birth* with Name * at Location*. Street Address City State Zip and/or Email and/or Fax Number .
Information to be released or exchanged (check all that apply)
Purpose of this release
If other, please describe the purpose:
This authorization expires on:

MonthDayYear
Your rights. I may revoke this authorization at any time by notifying Pillar in writing; revoking does not affect information already released. Signing this form is voluntary: my treatment, payment, enrollment or eligibility for benefits will not depend on whether I sign it. I have the right to inspect or get a copy of the information to be released, and to receive a copy of this form.

Redisclosure. Information released under this authorization may be shared again by the recipient and may no longer be protected by HIPAA. However, substance use disorder records protected by federal law (42 CFR Part 2) may not be shared again by the recipient except as Part 2 allows.
Client Full Name/Parent or Legal Guardian Full Name:

First NameLast Name
Client Signature/ Parent or Legal Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requesting Workers Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: