Authorization for Release of Health Information

Purpose of Disclosure

I authorize the information identified below to be used or disclosed for the purpose(s) I select in this form, such as coordination or continuity of treatment, consultation with another healthcare provider, transfer of care, personal use, insurance or benefits, a legal purpose, a school or educational purpose, a disability or accommodation request, or another purpose I specify.

Information Authorized for Release or Exchange

I authorize only the information specifically selected in this form to be released, obtained, or exchanged, except as otherwise permitted or required by law. This may include psychiatric evaluations, diagnoses, medication lists and history, medication-management records, treatment plans, progress notes, laboratory results, psychological or neuropsychological testing, hospitalization or discharge information, relevant medical history, coordination-of-care information, billing or insurance information, dates of treatment only, the entire record, or other specifically identified information, limited to the dates I specify.

Sensitive Health Information

I understand that my health record may contain sensitive information that may be subject to additional federal or state confidentiality protections. Where specific authorization is required by applicable law, I specifically authorize the disclosure or exchange of only the sensitive categories I select in this form, such as mental/behavioral health information, substance use disorder treatment information when applicable and legally permitted, HIV/AIDS or other specially protected communicable-disease information when applicable, genetic information or genetic testing information when applicable, or other specially protected information I identify.

I understand that certain categories of information may be subject to additional federal or state requirements concerning authorization, disclosure, and redisclosure.

Psychotherapy notes are not included in this general authorization. If disclosure of psychotherapy notes is requested and a separate authorization is required by applicable law, an appropriate separate authorization will be obtained.

Substance Use Disorder Records

I understand that certain records relating to substance use disorder diagnosis, treatment, or referral for treatment may be protected by additional federal confidentiality requirements, including 42 CFR Part 2, when applicable.

When these protections apply, Luminox Healthcare Services LLC will use or disclose such information only as permitted by applicable federal and state law.

Expiration of Authorization

This authorization becomes effective on the date it is signed and will expire on the date or specific event I specify. If no expiration date or event is specified, this authorization will expire 365 days from the date it is signed, unless a shorter period is required by applicable law.

Right to Revoke Authorization

I understand that I may revoke this authorization in writing at any time, except to the extent that Luminox Healthcare Services LLC or another authorized party has already taken action in reliance on this authorization or as otherwise provided by applicable law.

A written revocation may be submitted to Luminox Healthcare Services LLC by email at contact@luminoxmentalhealth.com, by fax at (240) 753-7279, or delivered to one of the practice locations listed above. Revocation will become effective as provided by applicable law and will not affect information that was lawfully used or disclosed before the revocation became effective.

Voluntary Authorization

I understand that signing this authorization is voluntary. Except as otherwise permitted by applicable law, Luminox Healthcare Services LLC will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits upon my signing this authorization.

I understand that if I decline to authorize communication with another healthcare provider or organization, it may in some circumstances limit Luminox Healthcare Services LLC's ability to coordinate my care effectively.

Potential Redisclosure

I understand that health information disclosed pursuant to this authorization may, depending upon the recipient and applicable law, no longer be protected by the HIPAA Privacy Rule and may potentially be redisclosed by the recipient.

However, I understand that certain information, including mental/behavioral health information, substance use disorder treatment information, and other specially protected health information, may remain subject to additional federal or state restrictions regarding disclosure and redisclosure.

Right to a Copy

I understand that I have the right to receive a copy of this signed authorization, and that a copy or electronically reproduced version of this properly completed and signed authorization may be used as permitted by applicable law.

Patient Authorization and Acknowledgment

By signing this authorization, I acknowledge that:

• I have read this authorization, have had it read to me, or have had its contents explained to me in a manner that I understand.
• I understand what health information I am authorizing Luminox Healthcare Services LLC to obtain, release, and/or exchange.
• I understand who is authorized to receive and/or disclose the information and the purpose of the disclosure.
• I understand that I may limit this authorization to specific information and dates.
• I understand that this authorization is voluntary.
• I understand when this authorization expires.
• I understand my right to revoke this authorization as described above.
• I understand the potential for redisclosure and that certain health information may have additional legal protections.
• I understand that psychotherapy notes are not included in this general authorization when a separate authorization is required.
• I understand that signing this authorization does not waive any rights or protections available to me under applicable federal or state law.
• I have had an opportunity to ask questions regarding this authorization, and my questions have been answered to my satisfaction.