Release of Information

(Please read this carefully and sign at the bottom)

We cannot discuss your program, progress or health information with anyone—not even your spouse or loved ones—without written permission.

Submit the form below to tell us with whom and what we can share.  Think ahead to your treatment and submit as many times as you need.  For instance, Spouse, Loved One, Doctors, Attorney, Parole Officer or person paying for your treatment should each be submitted separately.

One form per one person or organization.

 

I have read and understood the full terms as follows: (1) I allow my insurance company or group health plan to re-disclose my information as necessary for payment, for their internal business purposes, or if my insurance company or group health plan is required to make the disclosure by law. (2) I understand that my records are protected under Federal regulations governing the confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part 2) and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that this disclosure will reveal my presence as a patient at this treatment facility or that I am receiving this type of treatment. (3) I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it by contacting Core Recovery in writing. This consent will last for 180 days after I leave treatment, or, in the case of payment, when my account has been settled, unless the program and/or physician specified above is notified by me that I am revoking my consent.

Important Links

Orchard Medical Page
Enrollment Documents
Patient Portal (Nurses Only)