Medium

Available on

Apple Android Windows

Consent For Release Of Confidential Information About Alcohol Or Drug Information Mobile App

The "Consent For Release Of Confidential Information About Alcohol Or Drug Information" app is a easy tool to collect approvals from the patient. By filling and signing this consent form, you are allowing your health records listed on this form to be disclosed through a secure computer network operated by health care providers whom you identify, that are a part of the CSOC network. The purpose of sharing your health care information is to provide you with, better, more coordinated treatment. All drug, alcohol, mental health and physical health care providers or other entities participating will be able to share (disclose and receive) their records to the health care providers you identify. This will include all places that have provided you services. This includes, drug and alcohol programs, mental health programs, psychologists, clinics, hospitals, clinical laboratories, pharmacies, physicians, health care insurers, Medicare, Medicaid, etc. This app is ideal for health care providers.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Consent For Release Of Confidential Information About Alcohol Or Drug Information Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    By signing this consent form, you are allowing your health records listed on this form to be disc...

  • Ico statictext

    You will be asked to identify the health care providers and entities to whom you are permitting t...

  • Ico statictext

    I,

  • Ico textbox

    Name of Youth Member

  • Ico date

    Date of Birth

  • Ico statictext

    , authorize (check which category applies),

  • Ico checkbox

    All drug, alcohol and mental health programs in which I have been evaluated and/or treated, and o...

  • Ico checkbox

    Only the following drug, alcohol and mental health programs in which I have been evaluated and/or...

  • Ico signature

    Initials

  • Ico textbox

    1. Name of treatment facility or organization

  • Ico textbox

    2. Name of treatment facility or organization

  • Ico textbox

    3. Name of treatment facility or organization

  • Ico dropdown

    Item

  • Ico signature

    Initial

  • Ico statictext

    I further authorize the CSA to disclose this information to the following CSOC-affiliated health ...

  • Ico textbox

    Care Management Organization (CMO) - (Indicate County and Agency Name)

  • Ico signature

    Initial

  • Ico dropdown

    Provider

  • Ico signature

    Initials

  • Ico dropdown

    Provider

  • Ico signature

    Initials

  • Ico dropdown

    Provider

  • Ico signature

    Initials

  • Ico statictext

    I understand that the information available to the health care providers identified above include...

  • Ico signature

    Initial

  • Ico statictext

    I understand that I may revoke this consent at any time except to the extent that action has alre...

  • Ico date

    Date

  • Ico statictext

    , or one year from the date of my authorizing signature.

  • ...and More!

Related Health Care & Social Services Apps... and they're all free for GoCanvas subscribers!

App Name

New Customer Form

This new customer form mobile app provides simple new customer forms for service based companies such as dry cleaning, law...

App Name

School Injury Report - Simple Version

If you're a staff member at a school the School Injury Report Mobile App is perfect for collecting key accident/injury inf...

App Name

OSHA - Notice of Alleged Safety Viola...

"OSHA inspections for occupational safety can reveal health hazards and even imminent danger. This mobile app for the comp...

App Name

Parking Citation

The Parking Citation mobile app for police departments and parking services professionals makes it possible to generate ne...

App Name

Natural Gas - Pipeline Survey

The Natural Gas Pipeline Survey mobile app was designed specifically for the natural gas industry. Instead of using paper ...

App Name

VA Dem House Race - Political Canvass...

This VA Dem House Race Political Canvassing Form was developed to be an electronic form of a survey sent out by the Virgin...

App Name

Road Construction and Equipment Tracking

The Road Construction and Equipment Tracking mobile app for construction managers and road crews tracks employee time shee...

App Name

Apparel Retail Form

This handy apparel retail form mobile app was built for a mobile retail sales associate or sales assistant. Great for depa...

More Information