By filling out and signing this form, I (the under signed) give my rep at Cornerstone Recovery Coaching permission to request, submit or receive any / and all of the following information related to:
Alcohol / Drug Evaluation, Diagnosis, Treatment, Testing, Education and Outcome Information and Recommendations.
This information is necessary for: Diagnosis, Recommendations, Referral, Treatment and/or Legal Purposes Information collateral to the Alcohol / Drug Evaluation / and any Associated Case Mgmt.
This information may be communicated orally, in writing, and electronically and this Release of Confidential Information remains in effect for one (1) year from the signature date.
A photocopy, fax or electronically reproduced copy of this Release of Confidential Information shall be as effective as the original.
The client acknowledges by his/her signature that he/she understands that he/she has the right to refuse to sign this Release. The client further acknowledges they understand that any person, address, email address or phone number they regularly correspond with us through, is considered an acceptable route of communication / transmission unless otherwise specified. This Release of Confidential Information remains in effect until the above time limit unless specifically revoked by written notice to:
Cornerstone Recovery Coaching LLC
11100 Osgood St. (103) San Antonio, TX 78233
Phone: 1800-561-8085 / Fax: 800-561-8085
support@CornerstoneRecoveryCoaching.com
This information has been disclosed to you from records protected by Federal Confidentiality rules 42 CFR Part 2. The Federal rules prohibit you from 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. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.
