Form51 - [FORM 51-Use the top of this page for your...

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[ FORM 51 —Use the top of this page for your letterhead.] Re: the following patient: Date of birth: Dear Sir or Madam: Regarding the information you requested in a request-for-information form or consent-to-release-records form dated : q Please find attached the records or information you requested on the above-named patient. The charge for copying these records is $ . Please forward this amount with the same courtesy, trust, and dispatch as my staff and I have used in collecting and providing this information to you. Thank you. Also, please note the following points: 1. Protected-information disclosure notice: Drug and alcohol disclosure. This information has been disclosed to you from records whose confidentiality is protected by state and federal law. Federal regulations (42 C.F.R. Part 2, Sections 2.31(a) and 2.33) and state regulations prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. These regulations provide for a fine of up to $500 for the first offense and up to $5,000 for each subsequent offense. 2. This is strictly confidential material and is for the information of only the person to whom it is addressed. I can accept no responsibility if it is made available to any other person, including the patient. Redisclosure or retransfer of these records may be prohibited, and such redisclosure may subject you to civil and crimi-
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Form51 - [FORM 51-Use the top of this page for your...

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