ࡱ>  bjbj 4(z87$[[[[[666bddddddYjd66d[[yL[[bb[J7ڤ@vN006Z@4666dd666666666666 : State of Nevada Division of Public and Behavioral Health Authorization for the Release of Record Information Agency (check one): ___Rural Clinics ___NNAMHS (Northern NV Adult Mental Health Svcs.) ___Lakes Crossing ___SNAMHS (Southern NV Adult Mental Health Svcs.) Name: ________________________________ Soc. Sec. #:__________________DOB:___________________ INFORMATION TO BE RELEASED FROM: Name/Agency: Southern Nevada Adult Mental Health Services__________________________________________ Address: ____________________________________________________________________________________ INFORMATION TO BE RELEASED TO: Name/Agency: ___________________________________________________________________________________ Address: ____________________________________________________________________________________ PURPOSE OF RELEASE: _________________________________________________________________________ ______Written Disclosure ______Verbal Disclosure (Initial one or both disclosure types) INFORMATION TO BE RELEASED: (Individual must initial each item of information to be released) ______Consultation Reports ________History & Physical Exam ______Treatment Plans ______Diagnosis (psychiatrist) ________HIV/AIDS Info. ______Psychiatric Evaluation ______Discharge Summary ________Medication Records ______Psychological Assessment ______Drug and Alcohol Abuse Info. ________Progress Notes ______ General Summary Letter Only ______Other (Specify):____________________________________________________________________________________________________ INFORMATION FOR INFORMED CONSENT The confidentiality of medical, psychiatric and substance abuse information is protected by State and Federal Statutes, Rules and Regulations including Nevada Revised Statutes and Title 42 of the Code of Federal Regulations. These Statutes, Rules and Regulations require that the individual give informed consent prior to the release of any health/hospital records or information, except as specifically provided for within the Statutes, Rules and Regulations. A consent to release information will be considered valid only when it states: (1) who will release the information; (2) who will receive the information; (3) the purpose for which the information will be used; (4) what specific information will be released; and (5) when the consent will expire. The consent must contain the individuals or authorized representatives signature and the date of the signature. The authorized representative signing for the client must submit a copy of the legal document(s) granting this authority. This authorization for the Release of Medical Information waives any and all rights that the individual now has or in the future may have to bring any legal action against the releasing person/facility for any damages caused directly or indirectly by the release of this information or other confidential information. Upon request, the individual will be given a copy of the completed Authorization for the Release of Client Information. This authorization is effective immediately and is subject to revocation in writing at any time, except to the extent that action has already been taken in reliance thereon. Otherwise, this authorization expires________ days from the date of signing (but no longer than 365 days) or upon case closure, whichever occurs first. Date: _______________________ Date: ______________________________ ____________________________ ___________________________________ Signature of Parent/Guardian/Representative) Signature of Client ____________________________________ ____________________________________________ Relationship to Client Signature of Witness Southern Nevada Adult Mental Health Services Release of Information Consent Form AW 18 Rev. 8/2013 NAME: __________________________________ FILE NO:_________________________________ COST OF COPIES IS $.60 PER PAGE     OF-MOI-19 Attachment B 89GJKNmn     ! c K ] `  0 < a GIjkż񥖥񍄍h"75CJ\ho*5CJ\ *h"7ho*5>*CJ\ho*5>*CJ\ *h"7ho*5CJ\h<>5CJ\hj$5CJ\ hJ7CJ hhOCJ h"7CJhho*h"75CJ\ho*5CJ\ ho*CJ/9mn  w c J K   a  $^a$$a$$a$ k HIjk9:QR  RS,-$If"SWZx{,Hdsx~*+/25UVZz¸ªž†vrneVh"h"5>*CJ\aJh"5CJ\h"hnBhih"CJ h"h"hih"75CJ\hihO&O5CJ\hihc5CJ\hih"5CJ\aJhih"5\hih"5CJ\ho*5CJ\h"7ho*ho*5>*CJ\ho*5CJ\ *h"7ho*5CJ\!*+UVWX^\\}kd$$Ifl0\(dd t0644 layti $Ifgd" $Ifgd"7$If $$Ifa$gdi XYZz|}$a$gd"z{}~h"h"5>*CJ\aJ h1hnhnh jh U 21h:p"/ =!"#$h% $$If!vh5d5d#vd:V l t065dyti^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH @@@  Heading 1$$@&a$5\>@>  Heading 2$@& 5CJ\D@D  Heading 3$$@&a$ 5CJ\>@>  Heading 4$@& 5CJ\DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 2>@2 Title$a$5\4@4 Header  !4 4 Footer  !j#j " Table Grid7:V0PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  ( z  X8@0(  B S  ?^G_G `GaG,bGlcG,   9*urn:schemas-microsoft-com:office:smarttagsplace9*urn:schemas-microsoft-com:office:smarttagsState>*urn:schemas-microsoft-com:office:smarttags PostalCode x8Nyz|} k:Cz|} 33338GJKN !]`W Z x { ddx~VVyzz}}   8!]`W Z x { x~yzz|}} \, Y|%1"7J7<>l@nBO&OVV`hni66/YD" cj$o*fhOz|@P@UnknownG*Ax Times New Roman5Symbol3. *Cx ArialA$BCambria Math"hed&uu24drr3HP)?"2!xxState of Nevada Chris NagyrwernerOh+'0 E    $ 0<DLT\State of Nevada Chris Nagy Normal.dotmrwerner2Microsoft Office Word@F#@>@ұ,ڤ@ұ,ڤuGCVT$m  ġ &" WMFC: lVT$m EMF "   Rp@Times New Roman&p& "&T &Nc"&& UU@@ LdName/Agency<+C%<*%.%*T`>UU@@LT: _*T8>GUU@@RL__________________________________________________________________________________**)**)**))***)**)**)**)**)**)**)*)***)**)**)**)**)**)**)*)***)**)**)**)**)**)**)*)TTF>rUU@@FLP s- TTUU@@LP s- TVZUU@@ILAddress: ___________<..%%! *)**)**)**)TT7ZUU@@UIIL_________________________________________________________________________)***)**)**)**)**)**)**)*)***)**)**)**)**)**)**)*)***)**)**)**)**)**)**)*)TT6bZUU@@6ILP o- TT^UU@@LP - '% LdI _!??% ( TI UU@@ LpPURPOSE OF RELEASE3<<3A.7A3<877=.7T`J UU@@J LT: _r*T^ UU@@ HL________________________________________________________________________**)**)**)**)**)**)**)*)***)**)**)**)**)**)**)*)***)**)**)**)**)**)**)*)*TT^ UU@@^ LP c- TT y UU@@h LP - TP} UU@@ VL______Written Disclosure ______Verbal Disclosure (Initial one or both disclosure types***)**S%%.< %* .%%****)*<%%.*< %* .%% .**.%*%.*.. %* .%%*.% TT } UU@@ LP)TT }  UU@@ LP - TT 9 UU@@( LP - '% Ld ;  ; `!??% ( T= ' UU@@ LINFORMATION TO BE RELEASED: <3A<P<7 A<7A87=787</7<Rp@Times New Roman& & P$&!&NcP$&H!& "&4$&NcP$&H!& qaH!&P$& ZzraXG*Ax Times ew Roman|!&x0a%!&!&pza%!&Zdv% % % % % % T(= &" WMFC ̆ UU@@( Lp(Individual must  /.*..*D/!T =  UU@@ Ldinitial each.*%*%.TT = , UU@@ LP T - =  UU@@- #Litem of information to be released)&C*.*&C+*.*.%%%%* %.'% Ld(  ( !??% ( TT= & UU@@ LP -Rp@Times New Roman&p& "&T &Nc"&& %""%/"%TT 4   UU@@ q LP e=TT 4 /  UU@@ q LP ,TT0 4 [  UU@@0 q LP [,T[ 4  UU@@\ q L______Psychological Assessment"!!"!")"$"!"!06%TT4  UU@@q LP TT 4 / UU@@ q LP $ T  UU@@ "L______Drug and Alcohol Abuse Info."!!"!"0$""%%0"$"0%%$"TT S UU@@ LP TTT  UU@@T LP b,T 2 UU@@ Lx________Progress Notes"!!"!!"!)"!0"TT3 V UU@@3 LP $ T  UU@@ "L______ General Summary Letter Only"!!"!"3%!%%76"",3%!TT S UU@@ LP hTTT  UU@@T LP ,TT  UU@@ LP ,TT  UU@@ LP ,TT  UU@@ LP $ % % % T e UU@@W 3L______Other (Specify):_____________________________"!!"!"4%%%""!!"!!"!!!"!!"!!"!!"!!"!!"!!"T >e UU@@W GL_______________________________________________________________________!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!% % % TT> jh UU@@>W LP&" WMFC f - TTi  UU@@ LP - T  S % UU@@ LINFORMATION FOR INFORMED CONSENT <3A<P<7 A<3A< <4A<P7<<A<.7<8TTT % UU@@T  LP - TT(  UU@@s LP - % % % T<  UU@@ }LHThe confidentiality of medical, psychiatric and substance abuse information is protected by State and Federal Statutes, Rules-%"$$%""!6%"%!%""%%%%"%"%%%"6""%%"%%!%""%%)%!%"%0%TT  UU@@ LP oT n UU@@ Lland Regulations "%%0"%""% Tx hUU@@L\includi%%$T<i hUU@@i}LHng Nevada Revised Statutes and Title 42 of the Code of Federal Regulations. These Statutes, Rules and Regulations require th%!0!"$"0!%%"%"%%,"!!%0"$")$"0"%""%-$%"%0%"%%0"%""%%%$Ti KUU@@iLpat the individual "%$%!%%! T >kUU@@]Lhgive informed "!$!6%T? kUU@@?] Lhconsent prior"%%$"TT kUU@@]LP TL  kUU@@]ULto the release of any health/hospital records or information, except as specifically x"$"!"$"%!%%"$!"$"$"6""%!%"%!"T< 1kUU@@ ](Lprovided for within the Statutes, Rules %"!%$!1%$%%"%0% TlUU@@Lland Regulations."%%0"%""%TTlUU@@LP $ TTUU@@LP $ T<+QUU@@C}LHA consent to release information will be considered valid only when it states: (1) who will release the information; (2) who 0"%%""$!6""%0$"%$%!!%"%"1$%""1$"0"%$!6""%"1%"T,QUU@@,CLpwill receive the /0!% TRWUU@@Llinformation; (3%"6""%"TlXRUU@@XLX) the%TTRUU@@LP eT RUU@@#Lpurpose for which the information w%$%""1$%%$!6""%0TpRUU@@[Lill be used; (4) what specific information will be released; and (5) when the consent will %%%"1$"%%"6""%1$"%"%%"1$%%"%%1Rp @Times New Roman"&T &Nc"&& %!$!6""%0"!"$"!%%""%%"%%$!%%!$"0%""%$%TbUU@@bLxure may have to bring %6"!%"!"$%" TUU@@Lany legal action against th"%!!"!"%"!"%$T7UU@@vL8e releasing person/facility for any damages caused directly or indirectly by the release of this information or other "$"%"$!"!"%!%"6"!"%%$""%%"%!%"!%%"6""$!"% T<tiUU@@[}LHconfidential information. Upon request, the individual will be given a copy of the completed  Authorization for the Release o"$$%!%!6""%0$"%$%%%%!%$"0%!!%""%!!$"6%%"0%%!"!%"$0"!TuiUU@@u[ Lhf Client Info/%%"TiUU@@[ L`rmation. 6""%!TT iUU@@[LP $ TTkUU@@LP $ T< UU@@}LHThis authorization is effective immediately and is subject to revocation in writing at any time, except to the extent that ac-%"%%!""%!76%"!"%$%%"!"""%%0$"""%!6!%"%!%%""T 'UU@@ Ltion has already been taken "%$"""%!%$##% '% Ld) P)M!??% ( T)OUU@@A<Lin reliance thereon. Otherwise, this authorization expires_%"%%"%4%0%"%%!""%!%!Tx( OUU@@)AL\_______o!"!!"!"TT # OUU@@ ALP T$  OUU@@$ AL|days from the date of si$!!"6%%"!Tp k &" WMFC &OUU@@ ALXgning "%$"Rp@Times New Roman& & P$&!&NcP$&H!& "&4$&NcP$&H!& qaH!&P$& <ZzraXG*Ax Times ew Roman|!&x0a%!&!&pza%!&<Zdv% % % % % % Tl OUU@@l AL(but no longer than 365 days%%%!!%"%"%!"!%!"'% Ldl HMl H-!??% ( T#OUU@@AL|) or upon case closure, "%%"%""% TQ)UU@@L|whichever occurs first.1%%!!$TT*QMUU@@*LP $ TTUU@@LP $ % % % TdJHUU@@7LTDate<*%T`KHUU@@K7LT: _Z*T;HUU@@7Lx______________________)**)**)**)**)**)*)***)TT:SHUU@@:7LP TTTHUU@@T7LP ,TTHUU@@7LP ,TT HUU@@7LP ,Td ~ HUU@@ 7LTDate<*%T`  HUU@@ 7LT: _*T HUU@@ 7L_____________________________)**)**)**)**)**)*)***)**)**))TTHUU@@7LP - TTLUU@@LP - T4UU@@L____________________________***)**)**)**)**)**)**)*)***)TT3SUU@@3LP !TTTUU@@TLP e,TTUU@@LP ,TT UU@@LP ,T  UU@@ #L___________________________________***)**)**)**)**)**)**)*)***)**)**))TTUU@@LP - % % % T UUU@@G"LSignature of Parent/Guardian/Repre%"$"%!)!%4$"$"$0%T UUU@@G L`sentative)%"!TT UUU@@GLP dTT UUU@@GLP ,TT  UUU@@GLP ,TT  UUU@@ GLP ,T  UUU@@ G L` T  UUU@@ GLtSignature of Client$"$"%!0%TT  UUU@@ GLP w$ TTVUU@@LP $ T$TUU@@$L____________________________________"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!TTTUU@@TLP ,TTUU@@LP ,TT UU@@LP c,TT UU@@ ,L____________________________________________"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!!"!TTUU@@LP $ TT;UU@@-LP ,T>;UU@@-LxRelationship to Client0""%$%!0%TT>S;UU@@>-LP TTT;UU@@T-LP i,TT;UU@@-LP ,TT ;UU@@-LP ,TT  ;UU@@ -LP ,T  ;UU@@ - L` T  ;UU@@ -LtSignature of Witness$"$"%!B%TT ;UU@@ -LP s$ TT<UU@@yLP $!y  TTUU@@Ly P $% % %  TT KUU@@6,Ly Southern Nevada Adult Mental Health Services828!8,,8H,2282H88 ^,8!2N,2!88,,2,,(TT  KUU@@ 6Ly P 6 % % % TTMUU@@Ly P&" WMFC  $ % % % TUU@@Ly tRelease of Informati<%%* %* .*&C*TWUU@@Ly lon Consent Form*.<*.!%.3*&DTTXUU@@XLy P s- % % % TTDUU@@6Ly P $ TpFzUU@@Ly XAW 180B"!Tt{FUU@@{1Ly  TF~UU@@Ly  TFxUU@@Ly l TlyF UU@@yLy XRev. 0!Tp F UU@@ Ly X8/2013"!!"!TT F UU@@ Ly P "" ! s % % %  T<# GUU@@# }L sH T`HrUU@@HL sT TTUU@@yL sP $ % % % TD! ;KUU@@# 4)L sNAME: __________________________________HHY=2222222222222222222222222222222222TT;gKUU@@;4L sP -Rp@Times New Roman&8& &&Nc&& &&Nc&& qa&& \ZzraXG*Ax Times ew Roman)&x0a%&&pza%,&\Zdv% % %  TT# M@ UU@@# L sP % % %  Td#  UU@@# L sTFILE8!<=TT  UU@@ L sP TX  UU@@ L sPNOIHT`  UU@@ L sT:__22T - UU@@ L s_______________________________2222222222222222222222222222222TT-^ UU@@-L sP s2" '% Lduxu!??%  % Lduxu!??%  % Ldy y{!??%  % Ld   !??%  % Ld r {!??%  % Ldsvs!??%  % Ldsvs!??%  % Lduxu!??%  % Lduxu!??%  % Lduxu!??%  % Ldy y{!??%  % Ld   !??%  % Ld   !??%  % Ld r {!??%  % Ldsvs!??%  % Ldsvs!??%  % Ldsvs!??%  % % %  TTUU@@LP $ TT.UU@@ LP $ TT0{UU@@mLP s$ TT}UU@@LP $ % % % T9 'UU@@9LCOST OF COPIES IS $.60 PER PAGE s<A.7A3<A3 8. .***37<3<A8' % Ld9 &9y!|&WMFC??% ( TT  'UU@@ LP -% % ( 666666666666666666666666666666666666 6 66 6  6 66 6  6 66 6  6 66 6  6 66 6 66666666666666666666  c.@Times New Roman--- 2 /2cOF  2 /Bc-2 /EcMOIE  2 /]c-2 /asc19 e"2 /c 2 / cAttachment B   2 //c ,c'@Times New Roman---"2 ;cState of Nevada 2 ;Sc 2 G cDivision of 52 G cPublic and Behavioral Health 2 Gc  2 RcAuthorization 2 RcforE 2 R c 2 RctheE 2 Rc 72 RcRelease of Record Information 2 Rc  2 ]1c (2 i2cAgency (check one): 2 ic 2 ic #2 ic___Rural Clinics 2 ic 2 i c___E2 icNNAMHS ( 2 iK cNorthern NV 2 ic +2 icAdult Mental Health S 2 icvcs.)S 2 ic 2 ic @Times New Roman------2 tVc  2 t\c  2 tzc $ 2 tc ---X2 t3c___Lakes Crossing ___SNAMHS (Southern NV Ad 2 t cult Mental He 2 tcal2 tcth S2 tcvcs.)S 2 tc  2 2c 2 2cName2 Kc: _e2 VUc_______________________________ Soc. Sec. #:__________________DOB:___________________ 2 c ;2 2 cINFORMATION TO BE RELEASED FROM:   2 c  2 2c 2 2 cName/Agency: 2 qc M2 s,cSouthern Nevada Adult Mental Health Services J2 >*c__________________________________________ 2 c  2 2c 2 2cAd2 ?bcdress: ____________________________________________________________________________________ 2 c - @ ! 2-82 2cINFORMATION TO BE RELEASED TO:  2 c  2 2c 2 2 cName/Agency2 nc: _e2 xRc__________________________________________________________________________________ 2 c  2 2c 42 2cAddress: ___________y2 Ic_________________________________________________________________________ 2 c  2 2c - @ ! p 2-&2 2cPURPOSE OF RELEASE2 c: _ew2 Hc________________________________________________________________________ 2 c  2 !2c 2 ,2Vc______Written Disclosure ______Verbal Disclosure (Initial one or both disclosure types  2 ,c) 2 ,c  2 82c - @ ! /:%-52 C2cINFORMATION TO BE RELEASED:  @Times New Roman------%2 Cc(Individual must E2 C% cinitial each 2 CTc @2 CW#citem of information to be released)- @ !D- 2 Cc @Times New Roman---22 M2c______Consultation Reports 2 Mc 2 Mc $ 2 Mc $:2 Mc________History & Physical Exam 2 M]c  2 Mvc $+2 Mc______Treatment Plans 2 Mc 82 V2c______Diagnosis (psychiatrist) 2 Vc  2 Vc $ 2 Vc $,2 Vc________HIV/AIDS Info. 2 V<c  2 VRc $ 2 Vvc $%2 Vc______PsychiatricI 2 Vc 2 V cEvaluation 2 Vc 2 Vc  2 V c .2 _2c______Discharge Summary 2 _c 2 _c  2 _c  2 _c $22 _c________Medication Records 2 _Jc  2 _Rc $ 2 _vc $82 _c______Psychological Assessment 2 _ c 2 _)c >2 h2"c______Drug and Alcohol Abuse Info. 2 hc  2 hc $,2 hc________Progress Notes 2 h9c >2 r2"c______ General Summary Letter Only 2 rc 2 rc $ 2 rc $ 2 r c $ 2 r.c ---X2 {23c______Other (Specify):_____________________________v2 {Gc________________________________________________________________________--- 2 {c  2 2c ;2  cINFORMATION FOR INFORMED CONSENT   2 c  2 2c ---2 2}cThe confidentiality of medical, psychiatric and substance abuse information is protected by State and Federal Statutes, Rules 2 c #2 cand Regulations 2 2cincludi(2 J}cng Nevada Revised Statutes and Title 42 of the Code of Federal Regulations. These Statutes, Rules and Regulations require th&2 cat the individual  2 2cgive informed 2 d cconsent prior  2 c 2 Ucto the release of any health/hospital records or information, except as specifically G2 (cprovided for within the Statutes, Rules #2 2cand Regulations. 2 lc  2 2c 2 2}cA consent to release information will be considered valid only when it states: (1) who will release the information; (2) who %2 cwill receive the "2 2cinformation; (32 gc) thed 2 vc @2 x#cpurpose for which the information wu2 [cill be used; (4) what specific information will be released; and (5) when the consent will  @Times New Roman-@Times New Roman- @Times New Roman-@Times New Roman- @Times New Roman--2 2}cexpire. The consent must contain the individuals or authorized representatives signature and the date of the signature. T 2 che authorized 22 2crepresentative signing for 2 c 2 Octhe client must submit a copy of the legal document(s) granting this authority. 2 c  2 2c 2 2}cThis authorization for the Release of Medical Information waives any and all rights that the individual now has or in the fut,2 cure may have to bring 42 2cany legal action against thN2 vce releasing person/facility for any damages caused directly or indirectly by the release of this information or other 2 2}cconfidential information. Upon request, the individual will be given a copy of the completed Authorization for the Release o2  cf Client Info2  crmation.I 2 %c  2 2c 2 '2}cThis authorization is effective immediately and is subject to revocation in writing at any time, except to the extent that ac52 'ction has already been taken - @ ! )-e2 02<cin reliance thereon. Otherwise, this authorization expires_2 0c_______( 2 0c /2 0cdays from the date of si2 0hcgning @Times New Roman------52 0}c(but no longer than 365 days- @ !a1}-/2 0c) or upon case closure, .2 :2cwhichever occurs first.  2 :c  2 C2c ---2 N2cDate2 NFc: _e,2 NQc______________________ 2 Nc  2 Nc $ 2 Nc $ 2 N c $2 N.cDate2 NBc: _e72 NMc_____________________________ 2 Nc  2 Y2c 52 e2c____________________________ 2 ec  2 ec $ 2 ec $ 2 e c $@2 e.#c___________________________________ 2 ec --->2 n2"cSignature of Parent/Guardian/Repre2 n csentative) 2 nc  2 nc $ 2 n c $ 2 n.c $2 nR c (2 nfcSignature of Client_ 2 nc  2 x2c A2 2$c____________________________________ 2 c $ 2 c $ 2  c $M2 .,c____________________________________________ 2 c  2 2c $,2 VcRelationship to Client 2 c ! 2 c $ 2 c $ 2  c $ 2 .c $2 R c )2 fcSignature of Witness 2 c  2 2c ,1- 2 2-1 ---M2 2,-1Southern Nevada Adult Mental Health Services    2 %-1 --- 2 2-1 ---)2 ^-1Release of Informati"2 -1on Consent Form 2 -1 --- 2 2-1 2 2-1AW 18U2 L1-1 52 -1 "2 -1 2 -1Rev. 82 -18/2013 2 +-1 ',62--- 2 7}26 2 026 0 2 626 ---I2 7)26NAME: __________________________________  2 /26 @Times New Roman--- 2 726 ---2 726FILE 2 P26 2 S26NO 2 d26:__E:2 t26_______________________________ 2 -26 '- @ !--- @ !--- @ !--- @ !1-- @ !2-- @ !6-- @ !6-- @ !>--- @ !--- @ !--- @ !--- @ !>1-- @ !1-- @ !2-- @ !>6-- @ !6-- @ !6----  2 2c  2 2c  2 2c  2 2c ---:2 cCOST OF COPIES IS $.60 PER PAGE- @ !- 2 c "System????????- - ccccccbbbbbbbbbbbbbbbbaaaaaaaaaaaaaaaa՜.+,0t hp  <MHDSr State of Nevada< Authorization for the Release of Record InformationQAgency (check one): ___Rural Clinics ___NNAMHS (Northern NV Adult Mental HealtL___Lakes Crossing ___SNAMHS (Southern NV Adult Mental Health Svcs.)) INFORMATION FOR INFORMED CONSENTJ Date: _______________________ Date: ______________________________ Title Headings  !"#$%&'()*+,./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F18ڤData 1TableWordDocument4(SummaryInformation(-