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Release of Information Consent Form

 

Name:
Date of Birth:

 

Parent/Legal Guardian Name(if applicable):

 

Welcome to the Radiant Recovery Coaching Program!

 

To enhance your prospects for sustained recovery, your treatment provider, www (hereafter "Provider") has teamed with Radiant Interactive Group, Inc. (hereafter "Radiant") to make the Radiant Recovery Coaching Program (hereafter "Program") available to you. Your Provider's role will be to explain the benefits of the Program, enroll you into the Program, and oversee your participation in it by periodically monitoring your progress toward sustained recovery. Radiant's role will be to match you with a recovery coach, and facilitate your ongoing coaching sessions via the www.radiantrecoverycoaching.com web platform.

As a matter of disclosure only, fees paid by you to subscribe to, and participate in, the Program will be apportioned among your recovery team members including, but not limited to, your Provider, Radiant, your recovery coach, and other related service providers and vendors. Should you wish to know more about how the Program fees are apportioned among your recovery team members, a breakdown of the amounts paid to each member will be provided to you within 30 days of receipt of your written request.

Consent to share information

As a subscriber to, and participant in, the Program, you hereby understand, consent to, authorize, and agree that in order to best serve your recovery needs, it will be necessary for the information listed below to be released to, and shared between, your assigned recovery coach, your Provider, and Radiant, and their respective staff members, and your designated toxicology lab, if applicable, as follows:

  • Verbal and/or written information about my background and current personal/family situation
  • Verbal and/or written information about my health (physical, mental, and behavioral)
  • Verbal and/or written information about my goals
  • Verbal and/or written information about services I am engaged in and services that could support me
  • Verbal and/or written information about diagnoses, medical treatment notes, case notes, and program participation information and results. Psychotherapy notes and Drug & Alcohol Treatment notes will not be disclosed except as allowed by 42CFR Part II
  • Verbal and/or written information about my behavioral health screening results
  • Verbal and/or written information about my toxicology results and lab reports
  • Verbal and/or written information about my Recovery Plan
  • Verbal and/or written information about any relapses I may experience; and
  • Any and all other information deemed necessary to optimize my chances for sustained recovery

 

I understand that information that is currently covered by the Health Insurance Portability and Accountability Act (HIPAA) may be re-disclosed on the basis of this authorization and may no longer be protected by HIPAA privacy law.

Unless otherwise limited, this authorization is valid for 12 months (one year) from the date of my signature below. I understand I have the right to revoke this authorization at any time by submitting a written statement to Radiant and Provider, except to the extent that action has been taken on it.

I understand that this cancellation will not affect any information that was already released before the time that I revoked this authorization

I understand that upon submission of this Consent form a .PDF version of it bearing my electronic signature shall be stored on my “My Account” page on this web platform. I understand that I may access my signed copy of this form at all times by logging into the platform to retrieve it. I hereby agree that the .PDF version bearing my electronic signature shall be as binding as if signed by me using a paper version of this Consent form.

I have read the foregoing and understand what this authorization and consent means. I am satisfied with any explanations I have requested and received. Accordingly, I hereby approve the release and sharing of information as described above.

 

Participant/Parent/
Guardian Signature:
Sign Here:
Date:

 

NEED HELP WITH ELECTRONIC SIGNATURE?

Using touch-screen:

If your device has touch-screen capability, simply place your finger in the signature block, and sign your first and last name using your finger.

Using an external mouse:

If you have an external mouse, place your cursor in the signature block; left click your mouse and hold down; and then proceed to sign your first and last name by moving your mouse to replicate your signature.

Using an internal mouse

If you have an internal mouse (such as on a laptop), place your cursor in the signature block; left click your mouse and hold down with one hand; and then using your other hand, place your finger on the touch pad, and sign your first and last name.

Note: If your signature is not to your liking, you can always click the Reset button located in the signature block to start over.