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Submitted URL: https://www.roi.compdrug.org/
Effective URL: https://compdrug.jotform.com/compdrug/cdri
Submission: On October 26 via api from US — Scanned from US
Effective URL: https://compdrug.jotform.com/compdrug/cdri
Submission: On October 26 via api from US — Scanned from US
Form analysis 1 forms found in the DOM
Name: form_241494316859972 — POST https://compdrug.jotform.com/submit/241494316859972
<form class="jotform-form" onsubmit="return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();" action="https://compdrug.jotform.com/submit/241494316859972" method="post" name="form_241494316859972" id="241494316859972"
accept-charset="utf-8" autocomplete="off" novalidate="true"><input type="hidden" name="formID" value="241494316859972"><input type="hidden" id="JWTContainer" value=""><input type="hidden" id="cardinalOrderNumber" value=""><input type="hidden"
id="jsExecutionTracker" name="jsExecutionTracker" value="build-date-1729961603966=>init-started:1729961605181=>validator-called:1729961605541=>validator-mounted-false:1729961605541=>init-complete:1729961605549"><input type="hidden"
id="submitSource" name="submitSource" value="mounted"><input type="hidden" id="buildDate" name="buildDate" value="1729961603966">
<div id="formCoverLogo" style="margin-bottom:10px" class="form-cover-wrapper form-has-cover form-page-cover-image-align-left">
<div class="form-page-cover-image-wrapper" style="max-width:752px"><img src="https://www.jotform.com/uploads/compdrug547/form_files/CD%20Logo.5f060cd5073857.22972812.602d26f7395a08.11391354.png" class="form-page-cover-image" width="416"
height="140" aria-label="Form Logo" style="aspect-ratio:416/140"></div>
</div>
<div role="main" class="form-all">
<ul class="form-section page-section">
<li id="cid_1" class="form-input-wide" data-type="control_head" data-css-selector="id_1">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_1" class="form-header" data-component="header">Authorization/Consent to Release or Obtain Information</h2>
<div id="subHeader_1" class="form-subHeader">FORM B – CONSENT FOR RELEASE OF PART 2 PROGRAM (SUBSTANCE USE DISORDER PROVIDER) INFORMATION</div>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_2" data-css-selector="id_2">
<div id="cid_2" class="form-input-wide" data-layout="full">
<div id="text_2" class="form-html" data-component="text" tabindex="0">A Part 2 Program is a federally assisted: (i) individual or entity other than a general medical facility who holds itself out as providing, and provides, substance use
disorder (SUD) diagnosis, treatment, or referral for treatment; (ii) an identified unit within a general medical facility that holds itself out as providing, and provides, SUD diagnosis, treatment, or referral for treatment; or, (iii)
medical personnel or staff in a general medical facility whose primary function is provision of SUD diagnosis, treatment, or referral for treatment, and who are identified as such providers.</div>
</div>
</li>
<li id="cid_34" class="form-input-wide" data-type="control_head" data-css-selector="id_34">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_34" class="form-header" data-component="header">Section I</h2>
<div id="subHeader_34" class="form-subHeader">This section describes the individual whose information will be released</div>
</div>
</div>
</li>
<li class="form-line form-line-column form-col-1 jf-required" data-type="control_textbox" id="id_3" data-css-selector="id_3"><label class="form-label form-label-top form-label-auto" id="label_3" for="input_3" aria-hidden="false"> First
Name<span class="form-required">*</span> </label>
<div id="cid_3" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_3" name="q3_firstName" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" style="width:20px" size="20" data-component="textbox" aria-labelledby="label_3 sublabel_input_3" required="" value=""><label class="form-sub-label"
for="input_3" id="sublabel_input_3" style="min-height:13px">First name of individual whose information will be released</label></span> </div>
</li>
<li class="form-line form-line-column form-col-2" data-type="control_textbox" id="id_4" data-css-selector="id_4"><label class="form-label form-label-top form-label-auto" id="label_4" for="input_4" aria-hidden="false"> M.I. </label>
<div id="cid_4" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_4" name="q4_mi" data-type="input-textbox" class="form-textbox" data-defaultvalue=""
autocomplete="nope" style="width:20px" size="20" maxlength="1" data-component="textbox" aria-labelledby="label_4 sublabel_input_4" value=""><label class="form-sub-label" for="input_4" id="sublabel_input_4" style="min-height:13px">Middle
initial of individual whose information will be released</label></span> </div>
</li>
<li class="form-line form-line-column form-col-3 jf-required" data-type="control_textbox" id="id_5" data-css-selector="id_5"><label class="form-label form-label-top form-label-auto" id="label_5" for="input_5" aria-hidden="false"> Last Name<span
class="form-required">*</span> </label>
<div id="cid_5" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_5" name="q5_lastName" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" style="width:20px" size="20" data-component="textbox" aria-labelledby="label_5 sublabel_input_5" required="" value=""><label class="form-sub-label"
for="input_5" id="sublabel_input_5" style="min-height:13px">Last name of individual whose information will be released</label></span> </div>
</li>
<li class="form-line jf-required" data-type="control_datetime" id="id_6" data-css-selector="id_6"><label class="form-label form-label-top form-label-auto" id="label_6" for="lite_mode_6" aria-hidden="false"> Date of Birth<span
class="form-required">*</span> </label>
<div id="cid_6" class="form-input-wide jf-required" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate]" id="month_6" name="q6_dateOf[month]" type="tel" size="2" data-maxlength="2" data-age=""
maxlength="2" required="" autocomplete="off" aria-labelledby="label_6 sublabel_6_month" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> /</span><label class="form-sub-label" for="month_6"
id="sublabel_6_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate]" id="day_6" name="q6_dateOf[day]"
type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" required="" autocomplete="off" aria-labelledby="label_6 sublabel_6_day" value="" inputmode="numeric"><span class="date-separate"
aria-hidden="true"> /</span><label class="form-sub-label" for="day_6" id="sublabel_6_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input
class="form-textbox validate[required, limitDate]" id="year_6" name="q6_dateOf[year]" type="tel" size="4" data-maxlength="4" data-age="" maxlength="4" required="" autocomplete="off" aria-labelledby="label_6 sublabel_6_year"
value=""><label class="form-sub-label" for="year_6" id="sublabel_6_year" style="min-height:13px">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input
class="form-textbox validate[required, limitDate, validateLiteDate]" id="lite_mode_6" type="text" size="12" data-maxlength="12" data-age="" required="" data-format="mmddyyyy" data-seperator="/" placeholder="MM/DD/YYYY"
data-placeholder="MM/DD/YYYY" autocomplete="off" aria-labelledby="label_6 sublabel_6_litemode" value="" inputmode="numeric"><img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_6_pick"
src="https://compdrug.jotform.com/images/calendar.png" data-component="datetime" aria-hidden="false" data-allow-time="No" data-version="v2" aria-label="Choose Date" role="button" tabindex="0" aria-haspopup="dialog"
aria-expanded="false"><label class="form-sub-label" for="lite_mode_6" id="sublabel_6_litemode" style="min-height:13px">Date of Birth of individual whose information will be released</label></span>
</div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_7" data-css-selector="id_7"><label class="form-label form-label-top form-label-auto" id="label_7" for="input_7" aria-hidden="false"> Social Security Number </label>
<div id="cid_7" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_7" name="q7_socialSecurity" data-type="input-textbox"
class="form-textbox validate[Fill Mask]" data-defaultvalue="" autocomplete="nope" style="width:20px" size="20" data-masked="true" data-component="textbox" aria-labelledby="label_7 sublabel_input_7" value="" inputmode="text"
maskvalue="###-##-####"><label class="form-sub-label" for="input_7" id="sublabel_input_7" style="min-height:13px">Social Security Number of individual whose information will be released</label></span> </div>
</li>
<li class="form-line" data-type="control_address" id="id_8" data-css-selector="id_8"><label class="form-label form-label-top form-label-auto" id="label_8" for="input_8_addr_line1" aria-hidden="false"> Address </label>
<div id="cid_8" class="form-input-wide" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_8_addr_line1" name="q8_address[addr_line1]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="nope" data-component="address_line_1" aria-labelledby="label_8 sublabel_8_addr_line1" value=""
maxlength="100"><label class="form-sub-label" for="input_8_addr_line1" id="sublabel_8_addr_line1" style="min-height:13px">Address of individual whose information will be released</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField" style="display:none"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container"
style="vertical-align:top"><input type="text" id="input_8_addr_line2" name="q8_address[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="nope" data-component="address_line_2"
aria-labelledby="label_8 sublabel_8_addr_line2" value="" maxlength="100"><label class="form-sub-label" for="input_8_addr_line2" id="sublabel_8_addr_line2" style="min-height:13px">Street Address Line 2</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_8_city" name="q8_address[city]" class="form-textbox form-address-city" data-defaultvalue="" autocomplete="nope" data-component="city" aria-labelledby="label_8 sublabel_8_city" value="" maxlength="60"><label
class="form-sub-label" for="input_8_city" id="sublabel_8_city" style="min-height:13px">City</label></span></span><span class="form-address-line form-address-state-line jsTest-address-lineField "><span
class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_8_state" name="q8_address[state]" class="form-textbox form-address-state" data-defaultvalue="" autocomplete="nope" data-component="state"
aria-labelledby="label_8 sublabel_8_state" value="" maxlength="60"><label class="form-sub-label" for="input_8_state" id="sublabel_8_state" style="min-height:13px">State</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_8_postal" name="q8_address[postal]" class="form-textbox form-address-postal" data-defaultvalue="" autocomplete="nope" data-component="zip" aria-labelledby="label_8 sublabel_8_postal" value="" maxlength="20"><label
class="form-sub-label" for="input_8_postal" id="sublabel_8_postal" style="min-height:13px">Zip Code</label></span></span></div>
</div>
</div>
<div class="form-description" style="display: none;">
<div class="form-description-arrow"></div>
<div class="form-description-arrow-small"></div>
<div class="form-description-content">List the address of the individual whose information will be released. <br><br>For example, if you are going to release your information to another organization, please list your address here.</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_9" data-css-selector="id_9">
<div id="cid_9" class="form-input-wide" data-layout="full">
<div id="text_9" class="form-html" data-component="text" tabindex="0">I hereby authorize the disclosure of health information about the above individual as follows.</div>
</div>
</li>
<li id="cid_35" class="form-input-wide" data-type="control_head" data-css-selector="id_35">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_35" class="form-header" data-component="header">Section II</h2>
<div id="subHeader_35" class="form-subHeader">Person/Place that has the information needed</div>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_10" data-css-selector="id_10"><label class="form-label form-label-top form-label-auto" id="label_10" for="input_10" aria-hidden="false"> Disclosing Entity (Who has the
records?)<span class="form-required">*</span> </label>
<div id="cid_10" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_10" name="q10_disclosingEntity10" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" style="width:20px" size="20" data-component="textbox" aria-labelledby="label_10 sublabel_input_10" required="" value=""><label class="form-sub-label"
for="input_10" id="sublabel_input_10" style="min-height:13px">Name of Holder of Part 2 Program Information</label></span> </div>
</li>
<li class="form-line" data-type="control_phone" id="id_68" data-css-selector="id_68"><label class="form-label form-label-top form-label-auto" id="label_68" for="input_68_full"> Telephone Number </label>
<div id="cid_68" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_68_full" name="q68_telephoneNumber68[full]" data-type="mask-number"
class="mask-phone-number form-textbox validate[Fill Mask]" data-defaultvalue="" autocomplete="nope" style="width:310px" data-masked="true" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_68 sublabel_68_masked"
value="" inputmode="text" maskvalue="(###) ###-####"><label class="form-sub-label" for="input_68_full" id="sublabel_68_masked" style="min-height:13px">Telephone number of the organization that will disclose the
information</label></span> </div>
</li>
<li class="form-line" data-type="control_address" id="id_12" data-compound-hint=",,,,," data-css-selector="id_12"><label class="form-label form-label-top form-label-auto" id="label_12" for="input_12_addr_line1" aria-hidden="false"> Address
</label>
<div id="cid_12" class="form-input-wide" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_12_addr_line1" name="q12_address39[addr_line1]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="nope" data-component="address_line_1" aria-labelledby="label_12 sublabel_12_addr_line1" value=""
maxlength="100"><label class="form-sub-label" for="input_12_addr_line1" id="sublabel_12_addr_line1" style="min-height:13px">Disclosing Entity Address</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField" style="display:none"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container"
style="vertical-align:top"><input type="text" id="input_12_addr_line2" name="q12_address39[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="nope" data-component="address_line_2"
aria-labelledby="label_12 sublabel_12_addr_line2" value="" maxlength="100"><label class="form-sub-label" for="input_12_addr_line2" id="sublabel_12_addr_line2" style="min-height:13px">Street Address Line 2</label></span></span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_12_city" name="q12_address39[city]" class="form-textbox form-address-city" data-defaultvalue="" autocomplete="nope" data-component="city" aria-labelledby="label_12 sublabel_12_city" value="" maxlength="60"><label
class="form-sub-label" for="input_12_city" id="sublabel_12_city" style="min-height:13px">Disclosing Entity City</label></span></span><span class="form-address-line form-address-state-line jsTest-address-lineField "><span
class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_12_state" name="q12_address39[state]" class="form-textbox form-address-state" data-defaultvalue="" autocomplete="nope" data-component="state"
aria-labelledby="label_12 sublabel_12_state" value="" maxlength="60"><label class="form-sub-label" for="input_12_state" id="sublabel_12_state" style="min-height:13px">Disclosing Entity State</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_12_postal" name="q12_address39[postal]" class="form-textbox form-address-postal" data-defaultvalue="" autocomplete="nope" data-component="zip" aria-labelledby="label_12 sublabel_12_postal" value="" maxlength="20"><label
class="form-sub-label" for="input_12_postal" id="sublabel_12_postal" style="min-height:13px">Disclosing Entity Zip Code</label></span></span></div>
</div>
</div>
<div class="form-description" style="display: none;">
<div class="form-description-arrow"></div>
<div class="form-description-arrow-small"></div>
<div class="form-description-content">List the address of the organization that will release/disclose the information. <br><br>For example, if CompDrug will release the information, enter CompDrug's address. <br><br>If another organization
will release information to CompDrug, list that organization's address.</div>
</div>
</li>
<li class="form-line fixed-width jf-required" data-type="control_dropdown" id="id_74" data-css-selector="id_74"><label class="form-label form-label-top form-label-auto" id="label_74" for="input_74" aria-hidden="false"> The information is to be
provided to the following: (Who needs the records?)<span class="form-required">*</span> </label>
<div id="cid_74" class="form-input-wide jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_74" name="q74_theInformation74" style="width:610px" data-component="dropdown" required=""
aria-label="The information is to be provided to the following: (Who needs the records?)">
<option value="">Please Select</option>
<option value="Named Individual">Named Individual</option>
<option value="Named Third Party Payer">Named Third Party Payer</option>
<option value="Named Treatment Provider Entity">Named Treatment Provider Entity</option>
<option value="Named Non-Treatment Provider (such as an intermediary or research entity)">Named Non-Treatment Provider (such as an intermediary or research entity)</option>
</select> </div>
</li>
<li class="form-line always-hidden" data-type="control_textbox" id="id_76" data-css-selector="id_76"><label class="form-label form-label-top form-label-auto" id="label_76" for="input_76" aria-hidden="false"> namedIndividualX </label>
<div id="cid_76" class="form-input-wide always-hidden" data-layout="half"> <input type="text" id="input_76" name="q76_namedindividualx" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autocomplete="nope"
style="width:310px" size="310" data-component="textbox" aria-labelledby="label_76" value=""> </div>
</li>
<li class="form-line always-hidden" data-type="control_textbox" id="id_80" data-css-selector="id_80"><label class="form-label form-label-top form-label-auto" id="label_80" for="input_80" aria-hidden="false"> namedPayerX </label>
<div id="cid_80" class="form-input-wide always-hidden" data-layout="half"> <input type="text" id="input_80" name="q80_namedpayerx" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autocomplete="nope" style="width:310px"
size="310" data-component="textbox" aria-labelledby="label_80" value=""> </div>
</li>
<li class="form-line always-hidden" data-type="control_textbox" id="id_81" data-css-selector="id_81"><label class="form-label form-label-top form-label-auto" id="label_81" for="input_81" aria-hidden="false"> namedTreatmentProviderX </label>
<div id="cid_81" class="form-input-wide always-hidden" data-layout="half"> <input type="text" id="input_81" name="q81_namedtreatmentproviderx" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autocomplete="nope"
style="width:310px" size="310" data-component="textbox" aria-labelledby="label_81" value=""> </div>
</li>
<li class="form-line always-hidden" data-type="control_textbox" id="id_82" data-css-selector="id_82"><label class="form-label form-label-top form-label-auto" id="label_82" for="input_82" aria-hidden="false"> namedNonTreatmentProviderX </label>
<div id="cid_82" class="form-input-wide always-hidden" data-layout="half"> <input type="text" id="input_82" name="q82_namednontreatmentproviderx" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autocomplete="nope"
style="width:310px" size="310" data-component="textbox" aria-labelledby="label_82" value=""> </div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_textbox" id="id_43" data-css-selector="id_43"><label class="form-label form-label-top form-label-auto" id="label_43"
for="input_43" aria-hidden="false"> Name of Individual: (Name and relationship to patient)<span class="form-required">*</span> </label>
<div id="cid_43" class="form-input-wide always-hidden jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_43" name="q43_nameOf43" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_43 sublabel_input_43" required="" value=""><label class="form-sub-label"
for="input_43" id="sublabel_input_43" style="min-height:13px">Enter the name of the Named Individual who will receive the information</label></span> </div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_textbox" id="id_46" data-css-selector="id_46"><label class="form-label form-label-top form-label-auto" id="label_46"
for="input_46" aria-hidden="false"> Name of Third Party Payer<span class="form-required">*</span> </label>
<div id="cid_46" class="form-input-wide always-hidden jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_46" name="q46_nameOf46" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_46 sublabel_input_46" required="" value=""><label class="form-sub-label"
for="input_46" id="sublabel_input_46" style="min-height:13px">Enter the name of the Third Party Payer who will receive the information</label></span> </div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_textbox" id="id_47" data-css-selector="id_47"><label class="form-label form-label-top form-label-auto" id="label_47"
for="input_47" aria-hidden="false"> Name of Treatment Provider Entity<span class="form-required">*</span> </label>
<div id="cid_47" class="form-input-wide always-hidden jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_47" name="q47_nameOf47" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_47 sublabel_input_47" required="" value=""><label class="form-sub-label"
for="input_47" id="sublabel_input_47" style="min-height:13px">Enter the name of the Treatment Provider Agency who will receive the information</label></span> </div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_textbox" id="id_15" data-css-selector="id_15"><label class="form-label form-label-top form-label-auto" id="label_15"
for="input_15" aria-hidden="false"> a. Named Individual Participant(s):<span class="form-required">*</span> </label>
<div id="cid_15" class="form-input-wide always-hidden jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_15" name="q15_aNamed" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" style="width:20px" size="20" data-component="textbox" aria-labelledby="label_15 sublabel_input_15" required="" value=""><label
class="form-sub-label" for="input_15" id="sublabel_input_15" style="min-height:13px">Enter the name of the Named Individual Participant(s) who will receive the information</label></span> </div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_textbox" id="id_16" data-css-selector="id_16"><label class="form-label form-label-top form-label-auto" id="label_16"
for="input_16" aria-hidden="false"> b. Named Treatment Provider Entity Participant(s):<span class="form-required">*</span> </label>
<div id="cid_16" class="form-input-wide always-hidden jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_16" name="q16_bNamed" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" style="width:20px" size="20" data-component="textbox" aria-labelledby="label_16 sublabel_input_16" required="" value=""><label
class="form-sub-label" for="input_16" id="sublabel_input_16" style="min-height:13px">Enter the name of the Named Treatment Provider Entity Participant(s) who will receive the information</label></span> </div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_textbox" id="id_17" data-css-selector="id_17"><label class="form-label form-label-top form-label-auto" id="label_17"
for="input_17" aria-hidden="false"> c. Description of Group or Class of Treatment Provider Entity Participant(s):<span class="form-required">*</span> </label>
<div id="cid_17" class="form-input-wide always-hidden jf-required" data-layout="half"> <input type="text" id="input_17" name="q17_cDescription" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue=""
autocomplete="nope" style="width:20px" size="20" data-component="textbox" aria-labelledby="label_17" required="" value=""> </div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_57" data-css-selector="id_57"><label class="form-label form-label-top form-label-auto" id="label_57" for="input_57" aria-hidden="false"> Contact Information (for who the
records are to be sent to) e.g. telephone number, email address, fax number, street address, etc<span class="form-required">*</span> </label>
<div id="cid_57" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_57" name="q57_contactInformation57" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_57 sublabel_input_57" required="" value=""><label class="form-sub-label"
for="input_57" id="sublabel_input_57" style="min-height:13px">Enter contact information for the disclosure recipient in the box above. The agency that will disclose the information will use this information to contact the
recipient.</label></span> </div>
</li>
<li id="cid_36" class="form-input-wide" data-type="control_head" data-css-selector="id_36">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_36" class="form-header" data-component="header">Section III</h2>
<div id="subHeader_36" class="form-subHeader">This section describes disclosure reasons, information to be disclosed, and the period of time from which information should be released</div>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_checkbox" id="id_50" data-css-selector="id_50"><label class="form-label form-label-top form-label-auto" id="label_50" aria-hidden="false"> Reason for Disclosure<span
class="form-required">*</span> </label>
<div id="cid_50" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_50" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_50" type="checkbox"
class="form-checkbox validate[required]" id="input_50_0" name="q50_reasonFor50[]" required="" value="Guest Dosing"><label id="label_input_50_0" for="input_50_0">Guest Dosing</label></span><span class="form-checkbox-item"
style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_50" type="checkbox" class="form-checkbox validate[required]" id="input_50_1" name="q50_reasonFor50[]" required="" value="Transfer"><label
id="label_input_50_1" for="input_50_1">Transfer</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_50" type="checkbox"
class="form-checkbox validate[required]" id="input_50_2" name="q50_reasonFor50[]" required="" value="Continuity of Care"><label id="label_input_50_2" for="input_50_2">Continuity of Care</label></span><span class="form-checkbox-item"
style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_50" type="checkbox" class="form-checkbox validate[required]" id="input_50_3" name="q50_reasonFor50[]" required="" value="Legal Matters"><label
id="label_input_50_3" for="input_50_3">Legal Matters</label></span><span class="form-checkbox-item formCheckboxOther" style="clear:left"><input type="checkbox" class="form-checkbox-other form-checkbox validate[required]"
name="q50_reasonFor50[other]" id="other_50" tabindex="0" aria-label="Other Reason (specify below)" value="other"><label id="label_other_50" style="text-indent:0" for="other_50">Other Reason (specify below)</label><span
id="other_50_input" class="other-input-container is-none" style=""><input type="text" class="form-checkbox-other-input form-textbox" name="q50_reasonFor50[other]" data-otherhint="Other Reason (specify below)" size="15" id="input_50"
data-placeholder="Please type another option here" placeholder="Please type another option here"></span></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_checkbox" id="id_49" data-css-selector="id_49"><label class="form-label form-label-top form-label-auto" id="label_49" aria-hidden="false"> Health information to be disclosed<span
class="form-required">*</span> </label>
<div id="cid_49" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_49" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_49" type="checkbox"
class="form-checkbox validate[required]" id="input_49_0" name="q49_healthInformation[]" required="" value="Clinical Treatment Summary"><label id="label_input_49_0" for="input_49_0">Clinical Treatment Summary</label></span><span
class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_49" type="checkbox" class="form-checkbox validate[required]" id="input_49_1" name="q49_healthInformation[]" required=""
value="Demographics"><label id="label_input_49_1" for="input_49_1">Demographics</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_49" type="checkbox"
class="form-checkbox validate[required]" id="input_49_2" name="q49_healthInformation[]" required="" value="Dosing (Last 90 Days)"><label id="label_input_49_2" for="input_49_2">Dosing (Last 90 Days)</label></span><span
class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_49" type="checkbox" class="form-checkbox validate[required]" id="input_49_3" name="q49_healthInformation[]" required=""
value="Lab Testing"><label id="label_input_49_3" for="input_49_3">Lab Testing</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_49" type="checkbox"
class="form-checkbox validate[required]" id="input_49_4" name="q49_healthInformation[]" required="" value="Medical Progress Notes"><label id="label_input_49_4" for="input_49_4">Medical Progress Notes</label></span><span
class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_49" type="checkbox" class="form-checkbox validate[required]" id="input_49_5" name="q49_healthInformation[]" required=""
value="Toxicology Results (Last 90 Days)"><label id="label_input_49_5" for="input_49_5">Toxicology Results (Last 90 Days)</label></span><span class="form-checkbox-item formCheckboxOther" style="clear:left"><input type="checkbox"
class="form-checkbox-other form-checkbox validate[required]" name="q49_healthInformation[other]" id="other_49" tabindex="0" aria-label="Other Information (specify below)" value="other"><label id="label_other_49" style="text-indent:0"
for="other_49">Other Information (specify below)</label><span id="other_49_input" class="other-input-container is-none" style=""><input type="text" class="form-checkbox-other-input form-textbox" name="q49_healthInformation[other]"
data-otherhint="Other Information (specify below)" size="15" id="input_49" data-placeholder="Please type another option here" placeholder="Please type another option here"></span></span></div>
</div>
<div class="form-description" style="display: none;">
<div class="form-description-arrow"></div>
<div class="form-description-arrow-small"></div>
<div class="form-description-content">Choose the information that can be disclosed by this release form. <br><br>For example, if you choose "Dosing (Last 90 Days)" the disclosing entity can release your recent dosing history to the
recipient entity.</div>
</div>
</li>
<li class="form-line" data-type="control_inline" id="id_38" data-css-selector="id_38">
<div id="cid_38" class="form-input-wide" data-layout="full">
<div id="FITB_38" class="FITB formRender">
<p>Specify time period, if desired:<br>Release only information from the period <span id="id_38-date-2" data-type="datebox" class="FITB-inptCont" data-blot-id="date-2"><input class="form-textbox validate[validateLiteDate]"
id="lite_mode_38-date-2" type="text" data-format="mmddyyyy" size="12" data-seperator="-" placeholder="mm-dd-yyyy" style="width: 40px; max-width: 648px;" inputmode="numeric"><img class="newDefaultTheme-dateIcon icon-liteMode"
alt="Pick a Date" data-qtype="control_inline" id="input_38-date-2_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="false" data-allow-time="No" data-version="v2" aria-label="Choose Date"
role="button" tabindex="0" aria-haspopup="dialog" aria-expanded="false"><label for="lite_mode_38-date-2">Date</label><span style="display:none"><input type="tel" class="form-textbox" id="month_38-date-2"
name="q38_input93[date-2][month]" size="2" data-maxlength="2" maxlength="2" autocomplete="off" inputmode="numeric"><input type="tel" class="form-textbox" id="day_38-date-2" name="q38_input93[date-2][day]" size="2"
data-maxlength="2" maxlength="2" autocomplete="off" inputmode="numeric"><input type="tel" class="form-textbox" id="year_38-date-2" name="q38_input93[date-2][year]" size="4" data-maxlength="4" maxlength="4"
autocomplete="off"></span></span> to <span id="id_38-date-1" data-type="datebox" class="FITB-inptCont" data-blot-id="date-1"><input class="form-textbox validate[validateLiteDate]" id="lite_mode_38-date-1"
type="text" data-format="mmddyyyy" size="12" data-seperator="-" placeholder="mm-dd-yyyy" style="width: 40px; max-width: 648px;" inputmode="numeric"><img class="newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date"
data-qtype="control_inline" id="input_38-date-1_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="false" data-allow-time="No" data-version="v2" aria-label="Choose Date" role="button"
tabindex="0" aria-haspopup="dialog" aria-expanded="false"><label for="lite_mode_38-date-1">Date</label><span style="display:none"><input type="tel" class="form-textbox" id="month_38-date-1" name="q38_input93[date-1][month]" size="2"
data-maxlength="2" maxlength="2" autocomplete="off" inputmode="numeric"><input type="tel" class="form-textbox" id="day_38-date-1" name="q38_input93[date-1][day]" size="2" data-maxlength="2" maxlength="2" autocomplete="off"
inputmode="numeric"><input type="tel" class="form-textbox" id="year_38-date-1" name="q38_input93[date-1][year]" size="4" data-maxlength="4" maxlength="4" autocomplete="off"></span></span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_93" data-css-selector="id_93">
<div id="cid_93" class="form-input-wide" data-layout="full">
<div id="text_93" class="form-html" data-component="text" tabindex="0">
<p><span style="color: #ea3223;">Note: if Dosing or Toxicology Results from the last 90 days are requested, please ensure that an appropriate time period is chosen</span></p>
</div>
</div>
</li>
<li id="cid_37" class="form-input-wide" data-type="control_head" data-css-selector="id_37">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_37" class="form-header" data-component="header">Section IV</h2>
<div id="subHeader_37" class="form-subHeader">This section describes the date through which this release will be active and it collects signatures of the individual whose information will be disclosed, or a representative of that
individual </div>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_24" data-css-selector="id_24">
<div id="cid_24" class="form-input-wide" data-layout="full">
<div id="text_24" class="form-html" data-component="text" tabindex="0">This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at
any time by submitting written revocation in the manner specified by the disclosing entity, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will expire on
the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year.</div>
</div>
</li>
<li class="form-line" data-type="control_datetime" id="id_25" data-css-selector="id_25"><label class="form-label form-label-top form-label-auto" id="label_25" for="lite_mode_25" aria-hidden="false"> Expiration Date (Optional) </label>
<div id="cid_25" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="month_25" name="q25_expirationDate[month]" type="tel" size="2" data-maxlength="2" data-age=""
maxlength="2" autocomplete="off" aria-labelledby="label_25 sublabel_25_month" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> /</span><label class="form-sub-label" for="month_25"
id="sublabel_25_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="day_25" name="q25_expirationDate[day]"
type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" autocomplete="off" aria-labelledby="label_25 sublabel_25_day" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> /</span><label
class="form-sub-label" for="day_25" id="sublabel_25_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="year_25"
name="q25_expirationDate[year]" type="tel" size="4" data-maxlength="4" data-age="" maxlength="4" autocomplete="off" aria-labelledby="label_25 sublabel_25_year" value=""><label class="form-sub-label" for="year_25"
id="sublabel_25_year" style="min-height:13px">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_25" type="text"
size="12" data-maxlength="12" data-age="" data-format="mmddyyyy" data-seperator="/" placeholder="MM/DD/YYYY" data-placeholder="MM/DD/YYYY" autocomplete="off" aria-labelledby="label_25 sublabel_25_litemode" value=""
inputmode="numeric"><img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_25_pick" src="https://compdrug.jotform.com/images/calendar.png" data-component="datetime" aria-hidden="false" data-allow-time="No"
data-version="v2" aria-label="Choose Date" role="button" tabindex="0" aria-haspopup="dialog" aria-expanded="false"><label class="form-sub-label" for="lite_mode_25" id="sublabel_25_litemode" style="min-height:13px">Expiration Date of
Release</label></span>
</div>
</div>
<div class="form-description" style="display: none;">
<div class="form-description-arrow"></div>
<div class="form-description-arrow-small"></div>
<div class="form-description-content">Optionally enter date by which this release document should expire. For example, if 1/1/2026 is listed, this document will be valid until 12/31/2025.</div>
</div>
</li>
<li class="form-line" data-type="control_radio" id="id_72" data-css-selector="id_72"><label class="form-label form-label-top form-label-auto" id="label_72" aria-hidden="false"> Expiration Event (Optional) </label>
<div id="cid_72" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_72" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_72" type="radio"
class="form-radio" id="input_72_0" name="q72_expirationEvent" value="Guest Dosing Ends / Return to Clinic"><label id="label_input_72_0" for="input_72_0">Guest Dosing Ends / Return to Clinic</label></span><span class="form-radio-item"
style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_72" type="radio" class="form-radio" id="input_72_1" name="q72_expirationEvent" value="Discharge from CompDrug"><label id="label_input_72_1"
for="input_72_1">Discharge from CompDrug</label></span><span class="form-radio-item formRadioOther" style="clear:left"><input type="radio" class="form-radio-other form-radio" name="q72_expirationEvent" id="other_72" tabindex="0"
aria-label="Other Event (specify below)" value="other"><label id="label_other_72" style="text-indent:0" for="other_72">Other Event (specify below)</label><span id="other_72_input" class="other-input-container is-none" style=""><input
type="text" class="form-radio-other-input form-textbox" name="q72_expirationEvent[other]" data-otherhint="Other Event (specify below)" size="15" id="input_72" data-placeholder="Please type another option here"
placeholder="Please type another option here"></span></span></div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_71" data-css-selector="id_71">
<div id="cid_71" class="form-input-wide" data-layout="full">
<div id="text_71" class="form-html" data-component="text" tabindex="0"> Substance use disorder records of Part 2 programs disclosed pursuant to this Consent are protected by federal regulations and cannot be re-disclosed without my written
consent unless otherwise provided for in the regulations. Any information disclosed pursuant to this Consent other than substance use disorder records or records protected under another state law may be subject to re-disclosure by the
recipient. I might be denied services if I refuse to authorize disclosure of information for purposes of assessment, treatment, or payment relating to substance use disorder if refusal is permitted by state law. My refusal to authorize
disclosure of information for other purposes will not affect my ability to obtain treatment or services. If I have authorized disclosure to a generally described group or class of participants in an entity which is not my treatment
provider, upon my written request, I must be provided a list of entities to which my information has been disclosed pursuant to that general designation. </div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_83" data-css-selector="id_83"><label class="form-label form-label-top form-label-auto" id="label_83" aria-hidden="false"> Who authorizes this release?<span
class="form-required">*</span> </label>
<div id="cid_83" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_83" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_83" type="radio"
class="form-radio validate[required]" id="input_83_0" name="q83_whoAuthorizes" required="" value="The individual whose information will be released"><label id="label_input_83_0" for="input_83_0">The individual whose information will
be released</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_83" type="radio" class="form-radio validate[required]" id="input_83_1"
name="q83_whoAuthorizes" required="" value="A representative of the individual whose information will be released"><label id="label_input_83_1" for="input_83_1">A representative of the individual whose information will be
released</label></span></div>
</div>
</li>
<li class="form-line fixed-width always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_signature" id="id_32" data-css-selector="id_32"><label class="form-label form-label-top form-label-auto"
id="label_32" for="input_32" aria-hidden="false"> Signature of Individual<span class="form-required">*</span> </label>
<div id="cid_32" class="form-input-wide always-hidden jf-required" data-layout="half">
<div data-wrapper-react="true">
<div id="signature_pad_32" class="signature-pad-wrapper">
<div data-wrapper-react="true">
<!--[if IE 7]><script type="text/javascript" src="/js/vendor/json2.js"></script><![endif]-->
</div>
<div class="signature-line signature-wrapper signature-placeholder" data-component="signature">
<div id="sig_pad_32" data-width="650" data-height="175" data-id="32" data-required="true" class="pad validate[required]" aria-description="Use your pointer or touch input to draw your signature." aria-labelledby="label_32"
tabindex="0">
<div style="padding:0 !important; margin:0 !important;width: 100% !important; height: 0 !important; -ms-touch-action: none; touch-action: none;margin-top:-1em !important; margin-bottom:1em !important;"></div><canvas
class="jSignature" width="650" style="margin: 0px; padding: 0px; border: none; height: 175px; width: 650px; touch-action: none; background-color: rgb(255, 255, 255);" height="175"></canvas>
<div style="padding:0 !important; margin:0 !important;width: 100% !important; height: 0 !important; -ms-touch-action: none; touch-action: none;margin-top:-1.5em !important; margin-bottom:1.5em !important; position: relative;"></div>
</div><input type="hidden" name="q32_signatureOf" class="output4" id="input_32" value="">
</div>
<aside class="signature-pad-aside"><span class="clear-pad-btn clear-pad" role="button" tabindex="0">Clear</span></aside>
</div>
<div data-wrapper-react="true">
<script type="text/javascript">
window.signatureForm = true
</script>
</div>
</div>
</div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_datetime" id="id_56" data-css-selector="id_56"><label class="form-label form-label-top form-label-auto" id="label_56"
for="lite_mode_56" aria-hidden="false"> Signature Date<span class="form-required">*</span> </label>
<div id="cid_56" class="form-input-wide always-hidden jf-required" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate]" id="month_56" name="q56_signatureDate[month]" type="tel" size="2" data-maxlength="2"
data-age="" maxlength="2" required="" autocomplete="off" aria-labelledby="label_56 sublabel_56_month" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label"
for="month_56" id="sublabel_56_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate]" id="day_56"
name="q56_signatureDate[day]" type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" required="" autocomplete="off" aria-labelledby="label_56 sublabel_56_day" value="" inputmode="numeric"><span class="date-separate"
aria-hidden="true"> -</span><label class="form-sub-label" for="day_56" id="sublabel_56_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input
class="form-textbox validate[required, limitDate]" id="year_56" name="q56_signatureDate[year]" type="tel" size="4" data-maxlength="4" data-age="" maxlength="4" required="" autocomplete="off"
aria-labelledby="label_56 sublabel_56_year" value=""><label class="form-sub-label" for="year_56" id="sublabel_56_year" style="min-height:13px">Year</label></span></div><span class="form-sub-label-container"
style="vertical-align:top"><input class="form-textbox validate[required, limitDate, validateLiteDate]" id="lite_mode_56" type="text" size="12" data-maxlength="12" data-age="" required="" data-format="mmddyyyy" data-seperator="-"
placeholder="MM-DD-YYYY" data-placeholder="MM-DD-YYYY" autocomplete="off" aria-labelledby="label_56" value="" inputmode="numeric"><img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_56_pick"
src="https://compdrug.jotform.com/images/calendar.png" data-component="datetime" aria-hidden="false" data-allow-time="No" data-version="v2" aria-label="Choose Date" role="button" tabindex="0" aria-haspopup="dialog"
aria-expanded="false"><label class="form-sub-label is-empty" for="lite_mode_56" id="sublabel_56_litemode" style="min-height:13px"></label></span>
</div>
</div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_fullname" id="id_51" data-css-selector="id_51"><label class="form-label form-label-top form-label-auto" id="label_51"
for="first_51" aria-hidden="false"> Name of Individual<span class="form-required">*</span> </label>
<div id="cid_51" class="form-input-wide always-hidden jf-required" data-layout="full">
<div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="first_51" name="q51_nameOf[first]" class="form-textbox validate[required]" data-defaultvalue=""
autocomplete="nope" size="10" data-component="first" aria-labelledby="label_51 sublabel_51_first" required="" value=""><label class="form-sub-label" for="first_51" id="sublabel_51_first" style="min-height:13px">Signing Individual
First Name</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"><input type="text" id="last_51" name="q51_nameOf[last]" class="form-textbox validate[required]" data-defaultvalue=""
autocomplete="nope" size="15" data-component="last" aria-labelledby="label_51 sublabel_51_last" required="" value=""><label class="form-sub-label" for="last_51" id="sublabel_51_last" style="min-height:13px">Signing Individual Last
Name</label></span></div>
</div>
</li>
<li class="form-line fixed-width always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_signature" id="id_33" data-css-selector="id_33"><label class="form-label form-label-top form-label-auto"
id="label_33" for="input_33" aria-hidden="false"> Signature of Personal Representative<span class="form-required">*</span> </label>
<div id="cid_33" class="form-input-wide always-hidden jf-required" data-layout="half">
<div data-wrapper-react="true">
<div id="signature_pad_33" class="signature-pad-wrapper">
<div data-wrapper-react="true">
<!--[if IE 7]><script type="text/javascript" src="/js/vendor/json2.js"></script><![endif]-->
</div>
<div class="signature-line signature-wrapper signature-placeholder" data-component="signature">
<div id="sig_pad_33" data-width="650" data-height="175" data-id="33" data-required="true" class="pad validate[required]" aria-description="Use your pointer or touch input to draw your signature." aria-labelledby="label_33"
tabindex="0">
<div style="padding:0 !important; margin:0 !important;width: 100% !important; height: 0 !important; -ms-touch-action: none; touch-action: none;margin-top:-1em !important; margin-bottom:1em !important;"></div><canvas
class="jSignature" width="650" style="margin: 0px; padding: 0px; border: none; height: 175px; width: 650px; touch-action: none; background-color: rgb(255, 255, 255);" height="175"></canvas>
<div style="padding:0 !important; margin:0 !important;width: 100% !important; height: 0 !important; -ms-touch-action: none; touch-action: none;margin-top:-1.5em !important; margin-bottom:1.5em !important; position: relative;"></div>
</div><input type="hidden" name="q33_signatureOf33" class="output4" id="input_33" value="">
</div>
<aside class="signature-pad-aside"><span class="clear-pad-btn clear-pad" role="button" tabindex="0">Clear</span></aside>
</div>
<div data-wrapper-react="true">
<script type="text/javascript">
window.signatureForm = true
</script>
</div>
</div>
</div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_datetime" id="id_66" data-css-selector="id_66"><label class="form-label form-label-top form-label-auto" id="label_66"
for="lite_mode_66" aria-hidden="false"> Signature Date (Personal Representative)<span class="form-required">*</span> </label>
<div id="cid_66" class="form-input-wide always-hidden jf-required" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate]" id="month_66" name="q66_signatureDate66[month]" type="tel" size="2" data-maxlength="2"
data-age="" maxlength="2" required="" autocomplete="off" aria-labelledby="label_66 sublabel_66_month" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label"
for="month_66" id="sublabel_66_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate]" id="day_66"
name="q66_signatureDate66[day]" type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" required="" autocomplete="off" aria-labelledby="label_66 sublabel_66_day" value="" inputmode="numeric"><span class="date-separate"
aria-hidden="true"> -</span><label class="form-sub-label" for="day_66" id="sublabel_66_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input
class="form-textbox validate[required, limitDate]" id="year_66" name="q66_signatureDate66[year]" type="tel" size="4" data-maxlength="4" data-age="" maxlength="4" required="" autocomplete="off"
aria-labelledby="label_66 sublabel_66_year" value=""><label class="form-sub-label" for="year_66" id="sublabel_66_year" style="min-height:13px">Year</label></span></div><span class="form-sub-label-container"
style="vertical-align:top"><input class="form-textbox validate[required, limitDate, validateLiteDate]" id="lite_mode_66" type="text" size="12" data-maxlength="12" data-age="" required="" data-format="mmddyyyy" data-seperator="-"
placeholder="MM-DD-YYYY" data-placeholder="MM-DD-YYYY" autocomplete="off" aria-labelledby="label_66" value="" inputmode="numeric"><img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_66_pick"
src="https://compdrug.jotform.com/images/calendar.png" data-component="datetime" aria-hidden="false" data-allow-time="No" data-version="v2" aria-label="Choose Date" role="button" tabindex="0" aria-haspopup="dialog"
aria-expanded="false"><label class="form-sub-label is-empty" for="lite_mode_66" id="sublabel_66_litemode" style="min-height:13px"></label></span>
</div>
</div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_fullname" id="id_53" data-css-selector="id_53"><label class="form-label form-label-top form-label-auto" id="label_53"
for="first_53" aria-hidden="false"> Name of Personal Representative<span class="form-required">*</span> </label>
<div id="cid_53" class="form-input-wide always-hidden jf-required" data-layout="full">
<div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="first_53" name="q53_nameOf53[first]" class="form-textbox validate[required]"
data-defaultvalue="" autocomplete="nope" size="10" data-component="first" aria-labelledby="label_53 sublabel_53_first" required="" value=""><label class="form-sub-label" for="first_53" id="sublabel_53_first"
style="min-height:13px">Personal Representative First Name</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"><input type="text" id="last_53" name="q53_nameOf53[last]"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="nope" size="15" data-component="last" aria-labelledby="label_53 sublabel_53_last" required="" value=""><label class="form-sub-label" for="last_53"
id="sublabel_53_last" style="min-height:13px">Personal Representative Last Name</label></span></div>
</div>
</li>
<li class="form-line always-hidden jf-required form-field-hidden" style="display: none !important;" data-type="control_checkbox" id="id_26" data-css-selector="id_26"><label class="form-label form-label-top form-label-auto" id="label_26"
aria-hidden="false"> Relationship of Personal Representative<span class="form-required">*</span> </label>
<div id="cid_26" class="form-input-wide always-hidden jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_26" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_26" type="checkbox"
class="form-checkbox validate[required]" id="input_26_0" name="q26_relationshipOf[]" required="" value="Parent"><label id="label_input_26_0" for="input_26_0">Parent</label></span><span class="form-checkbox-item"
style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_26" type="checkbox" class="form-checkbox validate[required]" id="input_26_1" name="q26_relationshipOf[]" required="" value="Legal Guardian"><label
id="label_input_26_1" for="input_26_1">Legal Guardian</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_26" type="checkbox"
class="form-checkbox validate[required]" id="input_26_2" name="q26_relationshipOf[]" required="" value="Healthcare Power of Attorney"><label id="label_input_26_2" for="input_26_2">Healthcare Power of Attorney</label></span><span
class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_26" type="checkbox" class="form-checkbox validate[required]" id="input_26_3" name="q26_relationshipOf[]" required=""
value="Executor/Adminstrator"><label id="label_input_26_3" for="input_26_3">Executor/Adminstrator</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_26"
type="checkbox" class="form-checkbox validate[required]" id="input_26_4" name="q26_relationshipOf[]" required="" value="Other"><label id="label_input_26_4" for="input_26_4">Other</label></span><span class="form-checkbox-item"
style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_26" type="checkbox" class="form-checkbox validate[required]" id="input_26_5" name="q26_relationshipOf[]" required="" value="N/A"><label
id="label_input_26_5" for="input_26_5">N/A</label></span></div>
</div>
</li>
<li class="form-line always-hidden" data-type="control_radio" id="id_64" data-css-selector="id_64"><label class="form-label form-label-top form-label-auto" id="label_64" aria-hidden="false"> Method of Delivery (e.g. paper, fax, electronic)
</label>
<div id="cid_64" class="form-input-wide always-hidden" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_64" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_64" type="radio"
class="form-radio" id="input_64_0" name="q64_methodOf" value="Paper"><label id="label_input_64_0" for="input_64_0">Paper</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input
aria-describedby="label_64" type="radio" class="form-radio" id="input_64_1" name="q64_methodOf" value="Electronic"><label id="label_input_64_1" for="input_64_1">Electronic</label></span><span class="form-radio-item"
style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_64" type="radio" class="form-radio" id="input_64_2" name="q64_methodOf" value="Fax"><label id="label_input_64_2"
for="input_64_2">Fax</label></span><span class="form-radio-item formRadioOther" style="clear:left"><input type="radio" class="form-radio-other form-radio" name="q64_methodOf" id="other_64" tabindex="0"
aria-label="Other Method (specify below)" value="other"><label id="label_other_64" style="text-indent:0" for="other_64">Other Method (specify below)</label><span id="other_64_input" class="other-input-container is-none"
style=""><input type="text" class="form-radio-other-input form-textbox" name="q64_methodOf[other]" data-otherhint="Other Method (specify below)" size="15" id="input_64" data-placeholder="Please type another option here"
placeholder="Please type another option here"></span></span></div>
</div>
</li>
<li class="form-line always-hidden" data-type="control_datetime" id="id_30" data-css-selector="id_30"><label class="form-label form-label-top form-label-auto" id="label_30" for="lite_mode_30" aria-hidden="false"> Date Released </label>
<div id="cid_30" class="form-input-wide always-hidden" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="month_30" name="q30_dateReleased[month]" type="tel" size="2" data-maxlength="2" data-age=""
maxlength="2" autocomplete="off" aria-labelledby="label_30 sublabel_30_month" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> /</span><label class="form-sub-label" for="month_30"
id="sublabel_30_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="day_30" name="q30_dateReleased[day]" type="tel"
size="2" data-maxlength="2" data-age="" maxlength="2" autocomplete="off" aria-labelledby="label_30 sublabel_30_day" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> /</span><label
class="form-sub-label" for="day_30" id="sublabel_30_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="year_30"
name="q30_dateReleased[year]" type="tel" size="4" data-maxlength="4" data-age="" maxlength="4" autocomplete="off" aria-labelledby="label_30 sublabel_30_year" value=""><label class="form-sub-label" for="year_30" id="sublabel_30_year"
style="min-height:13px">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_30" type="text" size="12"
data-maxlength="12" data-age="" data-format="mmddyyyy" data-seperator="/" placeholder="MM/DD/YYYY" data-placeholder="MM/DD/YYYY" autocomplete="off" aria-labelledby="label_30 sublabel_30_litemode" value="" inputmode="numeric"><img
class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_30_pick" src="https://compdrug.jotform.com/images/calendar.png" data-component="datetime" aria-hidden="false" data-allow-time="No" data-version="v2"
aria-label="Choose Date" role="button" tabindex="0" aria-haspopup="dialog" aria-expanded="false"><label class="form-sub-label" for="lite_mode_30" id="sublabel_30_litemode" style="min-height:13px">Date</label></span>
</div>
</div>
</li>
<li class="form-line always-hidden" data-type="control_calculation" id="id_61" data-css-selector="id_61"><label class="form-label form-label-top form-label-auto" id="label_61" for="input_61" aria-hidden="false"> Calculation </label>
<div id="cid_61" class="form-input-wide always-hidden" data-layout="half"> <input aria-labelledby="label_61" data-component="calculation" type="text" data-defaultvalue="0" class="form-textbox" data-type="input-textbox" id="input_61"
name="q61_calculation" size="20" value="0"> </div>
</li>
<li class="form-line always-hidden" data-type="control_calculation" id="id_62" data-css-selector="id_62"><label class="form-label form-label-top form-label-auto" id="label_62" for="input_62" aria-hidden="false"> Calculation </label>
<div id="cid_62" class="form-input-wide always-hidden" data-layout="half"> <input aria-labelledby="label_62" data-component="calculation" type="text" data-defaultvalue="0" class="form-textbox" data-type="input-textbox" id="input_62"
name="q62_calculation62" size="20" value="0"> </div>
</li>
<li class="form-line always-hidden" data-type="control_calculation" id="id_65" data-css-selector="id_65"><label class="form-label form-label-top form-label-auto" id="label_65" for="input_65" aria-hidden="false"> Calculation </label>
<div id="cid_65" class="form-input-wide always-hidden" data-layout="half"> <input aria-labelledby="label_65" data-component="calculation" type="text" data-defaultvalue="0" class="form-textbox" data-type="input-textbox" id="input_65"
name="q65_calculation65" size="20" value="0"> </div>
</li>
<li class="form-line always-hidden" data-type="control_calculation" id="id_67" data-css-selector="id_67"><label class="form-label form-label-top form-label-auto" id="label_67" for="input_67" aria-hidden="false"> Calculation </label>
<div id="cid_67" class="form-input-wide always-hidden" data-layout="half"> <input aria-labelledby="label_67" data-component="calculation" type="text" data-defaultvalue="0" class="form-textbox" data-type="input-textbox" id="input_67"
name="q67_calculation67" size="20" value="0"> </div>
</li>
<li class="form-line always-hidden" data-type="control_calculation" id="id_73" data-css-selector="id_73"><label class="form-label form-label-top form-label-auto" id="label_73" for="input_73" aria-hidden="false"> Calculation </label>
<div id="cid_73" class="form-input-wide always-hidden" data-layout="half"> <input aria-labelledby="label_73" data-component="calculation" type="text" data-defaultvalue="0" class="form-textbox" data-type="input-textbox" id="input_73"
name="q73_calculation73" size="20" value="0"> </div>
</li>
<li class="form-line always-hidden" data-type="control_widget" id="id_89" data-css-selector="id_89">
<div id="cid_89" class="form-input always-hidden" data-layout="full" style="display: inline-block;">
<div style="width:100%;text-align:Left" data-component="widget-directEmbed">
<div class="direct-embed-widgets substring-widget " data-type="direct-embed" style="width:200px;min-height:30px">
<script src="//widgets.jotform.io/substring/substring.min.js"></script>
<script type="text/javascript">
if (window.JFWidgetSubstrSetup) {
window.JFWidgetSubstrSetup({
"qid": "89",
"source": "input_3",
"start": "0",
"end": "1",
"qname": "q89_substr1"
});
}
</script>
<div id="input_89_container"><input type="text" id="input_89" name="q89_substr1" readonly="readonly" class="form-textbox substring" style="box-sizing: border-box; width: 200px;"></div>
</div>
</div>
</div>
</li>
<li class="form-line always-hidden" data-type="control_widget" id="id_90" data-css-selector="id_90">
<div id="cid_90" class="form-input always-hidden" data-layout="full" style="display: inline-block;">
<div style="width:100%;text-align:Left" data-component="widget-directEmbed">
<div class="direct-embed-widgets substring-widget " data-type="direct-embed" style="width:200px;min-height:30px">
<script src="//widgets.jotform.io/substring/substring.min.js"></script>
<script type="text/javascript">
if (window.JFWidgetSubstrSetup) {
window.JFWidgetSubstrSetup({
"qid": "90",
"source": "input_5",
"start": "0",
"end": "1",
"qname": "q90_substr2"
});
}
</script>
<div id="input_90_container"><input type="text" id="input_90" name="q90_substr2" readonly="readonly" class="form-textbox substring" style="box-sizing: border-box; width: 200px;"></div>
</div>
</div>
</div>
</li>
<li class="form-line always-hidden" data-type="control_widget" id="id_91" data-css-selector="id_91">
<div id="cid_91" class="form-input always-hidden" data-layout="full" style="display: inline-block;">
<div style="width:100%;text-align:Left" data-component="widget-directEmbed">
<div class="direct-embed-widgets substring-widget " data-type="direct-embed" style="width:200px;min-height:30px">
<script src="//widgets.jotform.io/substring/substring.min.js"></script>
<script type="text/javascript">
if (window.JFWidgetSubstrSetup) {
window.JFWidgetSubstrSetup({
"qid": "91",
"source": "year_6",
"start": "2",
"end": "4",
"qname": "q91_substr3"
});
}
</script>
<div id="input_91_container"><input type="text" id="input_91" name="q91_substr3" readonly="readonly" class="form-textbox substring" style="box-sizing: border-box; width: 200px;"></div>
</div>
</div>
</div>
</li>
<li class="form-line always-hidden" data-type="control_textbox" id="id_92" data-css-selector="id_92"><label class="form-label form-label-top form-label-auto" id="label_92" for="input_92" aria-hidden="false"> cmpn </label>
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to you for any clarifications before releasing your information. This option is provided for your convenience so that your request can be completed as quickly as possible. If you do not authorize a specific phone number, your
request may be delayed. CompDrug will attempt to contact you based on existing information on record.</div>
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with any questions about my Release of Information request<span class="form-required">*</span> </label>
<div id="cid_85" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><select class="form-dropdown validate[required]" id="input_85" name="q85_iAuthorize85"
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<option value="">Please Select</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select><label class="form-sub-label" for="input_85" id="sublabel_input_85" style="min-height:13px">If you select No, CompDrug will still attempt to reach you using existing contact information on record if items on this form require
clarification. This may delay the release of your information.</label></span> </div>
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for="input_87_full"> Phone Number<span class="form-required">*</span> </label>
<div id="cid_87" class="form-input-wide always-hidden jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_87_full" name="q87_phoneNumber[full]" data-type="mask-number"
class="mask-phone-number form-textbox validate[required, Fill Mask]" data-defaultvalue="" autocomplete="nope" style="width:310px" data-masked="true" placeholder="(000) 000-0000" data-component="phone"
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Release ID (for reference only) </label>
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* AUTHORIZATION/CONSENT TO RELEASE OR OBTAIN INFORMATION FORM B – CONSENT FOR RELEASE OF PART 2 PROGRAM (SUBSTANCE USE DISORDER PROVIDER) INFORMATION * A Part 2 Program is a federally assisted: (i) individual or entity other than a general medical facility who holds itself out as providing, and provides, substance use disorder (SUD) diagnosis, treatment, or referral for treatment; (ii) an identified unit within a general medical facility that holds itself out as providing, and provides, SUD diagnosis, treatment, or referral for treatment; or, (iii) medical personnel or staff in a general medical facility whose primary function is provision of SUD diagnosis, treatment, or referral for treatment, and who are identified as such providers. * SECTION I This section describes the individual whose information will be released * First Name* First name of individual whose information will be released * M.I. Middle initial of individual whose information will be released * Last Name* Last name of individual whose information will be released * Date of Birth* /Month /DayYear Date of Birth of individual whose information will be released * Social Security Number Social Security Number of individual whose information will be released * Address Address of individual whose information will be released Street Address Line 2 CityState Zip Code List the address of the individual whose information will be released. For example, if you are going to release your information to another organization, please list your address here. * I hereby authorize the disclosure of health information about the above individual as follows. * SECTION II Person/Place that has the information needed * Disclosing Entity (Who has the records?)* Name of Holder of Part 2 Program Information * Telephone Number Telephone number of the organization that will disclose the information * Address Disclosing Entity Address Street Address Line 2 Disclosing Entity CityDisclosing Entity State Disclosing Entity Zip Code List the address of the organization that will release/disclose the information. For example, if CompDrug will release the information, enter CompDrug's address. If another organization will release information to CompDrug, list that organization's address. * The information is to be provided to the following: (Who needs the records?)* Please Select Named Individual Named Third Party Payer Named Treatment Provider Entity Named Non-Treatment Provider (such as an intermediary or research entity) * namedIndividualX * namedPayerX * namedTreatmentProviderX * namedNonTreatmentProviderX * Name of Individual: (Name and relationship to patient)* Enter the name of the Named Individual who will receive the information * Name of Third Party Payer* Enter the name of the Third Party Payer who will receive the information * Name of Treatment Provider Entity* Enter the name of the Treatment Provider Agency who will receive the information * a. Named Individual Participant(s):* Enter the name of the Named Individual Participant(s) who will receive the information * b. Named Treatment Provider Entity Participant(s):* Enter the name of the Named Treatment Provider Entity Participant(s) who will receive the information * c. Description of Group or Class of Treatment Provider Entity Participant(s):* * Contact Information (for who the records are to be sent to) e.g. telephone number, email address, fax number, street address, etc* Enter contact information for the disclosure recipient in the box above. The agency that will disclose the information will use this information to contact the recipient. * SECTION III This section describes disclosure reasons, information to be disclosed, and the period of time from which information should be released * Reason for Disclosure* Guest DosingTransferContinuity of CareLegal MattersOther Reason (specify below) * Health information to be disclosed* Clinical Treatment SummaryDemographicsDosing (Last 90 Days)Lab TestingMedical Progress NotesToxicology Results (Last 90 Days)Other Information (specify below) Choose the information that can be disclosed by this release form. For example, if you choose "Dosing (Last 90 Days)" the disclosing entity can release your recent dosing history to the recipient entity. * Specify time period, if desired: Release only information from the period Date to Date * Note: if Dosing or Toxicology Results from the last 90 days are requested, please ensure that an appropriate time period is chosen * SECTION IV This section describes the date through which this release will be active and it collects signatures of the individual whose information will be disclosed, or a representative of that individual * This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at any time by submitting written revocation in the manner specified by the disclosing entity, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will expire on the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year. * Expiration Date (Optional) /Month /DayYear Expiration Date of Release Optionally enter date by which this release document should expire. For example, if 1/1/2026 is listed, this document will be valid until 12/31/2025. * Expiration Event (Optional) Guest Dosing Ends / Return to ClinicDischarge from CompDrugOther Event (specify below) * Substance use disorder records of Part 2 programs disclosed pursuant to this Consent are protected by federal regulations and cannot be re-disclosed without my written consent unless otherwise provided for in the regulations. Any information disclosed pursuant to this Consent other than substance use disorder records or records protected under another state law may be subject to re-disclosure by the recipient. I might be denied services if I refuse to authorize disclosure of information for purposes of assessment, treatment, or payment relating to substance use disorder if refusal is permitted by state law. My refusal to authorize disclosure of information for other purposes will not affect my ability to obtain treatment or services. If I have authorized disclosure to a generally described group or class of participants in an entity which is not my treatment provider, upon my written request, I must be provided a list of entities to which my information has been disclosed pursuant to that general designation. * Who authorizes this release?* The individual whose information will be releasedA representative of the individual whose information will be released * Signature of Individual* Clear * Signature Date* -Month -DayYear * Name of Individual* Signing Individual First NameSigning Individual Last Name * Signature of Personal Representative* Clear * Signature Date (Personal Representative)* -Month -DayYear * Name of Personal Representative* Personal Representative First NamePersonal Representative Last Name * Relationship of Personal Representative* ParentLegal GuardianHealthcare Power of AttorneyExecutor/AdminstratorOtherN/A * Method of Delivery (e.g. paper, fax, electronic) PaperElectronicFaxOther Method (specify below) * Date Released /Month /DayYear Date * Calculation * Calculation * Calculation * Calculation * Calculation * * * * cmpn * CompDrug may need to contact you to confirm information on this request. Below, you have the option to provide approval and a phone number for CompDrug to reach out to you for any clarifications before releasing your information. This option is provided for your convenience so that your request can be completed as quickly as possible. If you do not authorize a specific phone number, your request may be delayed. CompDrug will attempt to contact you based on existing information on record. * I authorize CompDrug to contact me with any questions about my Release of Information request* Please Select Yes No If you select No, CompDrug will still attempt to reach you using existing contact information on record if items on this form require clarification. This may delay the release of your information. * Phone Number* Please enter a valid phone number for CompDrug to contact you with any questions about your request * Preview PDF Submit * CompDrug Release ID (for reference only) * Should be Empty: October‹› 2024«» October 2024TodaySMTWTFS29301234567891011121314151617181920212223242526272829303112345678910111213141516 October‹› 2024«» October 2024TodaySMTWTFS29301234567891011121314151617181920212223242526272829303112345678910111213141516 October‹› 2024«» October 2024TodaySMTWTFS29301234567891011121314151617181920212223242526272829303112345678910111213141516 October‹› 2024«» October 2024TodaySMTWTFS29301234567891011121314151617181920212223242526272829303112345678910111213141516 October‹› 2024«» October 2024TodaySMTWTFS29301234567891011121314151617181920212223242526272829303112345678910111213141516 October‹› 2024«» October 2024TodaySMTWTFS29301234567891011121314151617181920212223242526272829303112345678910111213141516 October‹› 2024«» October 2024TodaySMTWTFS29301234567891011121314151617181920212223242526272829303112345678910111213141516 Back to Form Clone of FORM B – CONSENT FOR RELEASE OF PART 2 PROGRAM (SUD PROVIDER) INFO