Complete this authorization and print it. Do not send health information through the website contact form or ordinary email.

Authorization to Release Medical and Health Information

Form version — July 30, 2026

Harbor & Haven Home Care, LLC
1520 Belle View Blvd., Suite 5517
Alexandria, VA 22307
Telephone (202) 834-7910
support@harborhavencare.org

Please complete all applicable sections. This form authorizes Harbor & Haven to disclose the records identified below. A separate authorization may be needed if another provider is releasing records to Harbor & Haven. Do not use this form for an emergency.

1. Individual whose information may be released

Full legal name

Date of birth

Current address

City, state, ZIP

Telephone

Client or record number, if known

2. Person or organization authorized to disclose information

I authorize Harbor & Haven Home Care, LLC, including its authorized workforce members and record-service vendors, to disclose the information described in this authorization.

3. Person or organization authorized to receive information

Recipient name or organization

Attention

Mailing address

City, state, ZIP

Telephone

Fax

Secure email

Preferred delivery method

Secure electronic delivery Encrypted email or approved secure portal Fax to the number listed above Mail Pick up by the individual or authorized representative Other

Other delivery method

4. Information authorized for release

Select the records to be disclosed. Harbor & Haven will release only records it maintains and may exclude information that another law does not permit it to redisclose.

Entire Harbor & Haven client record for the date range below Service plan, assessment, and updates Caregiver visit notes, task records, and wellness observations Medication reminder or medication-list information maintained by Harbor & Haven Scheduling, attendance, and service-verification records Billing, payment, insurance, Medicaid, or authorization records Incident, safety, transition, or care-coordination records Communications with the client, representative, family, provider, or payor

Other specific information

Date range from

Through

Service location, if relevant

5. Specially protected information

Initial each category only if you specifically authorize its release. Harbor & Haven will apply any additional federal or Virginia requirement that protects the information. Records not maintained by Harbor & Haven cannot be released by Harbor & Haven.

Behavioral or mental health information — initials

HIV, AIDS, or communicable-disease information — initials

Genetic-testing information — initials

Substance use disorder information — initials, and only if legally permitted

Other sensitive information — initials

Describe other sensitive information

Psychotherapy notes are not included. HIPAA generally requires a separate authorization for psychotherapy notes. Federally protected substance use disorder records under 42 CFR Part 2 may also require a separate, specifically worded consent or court order.

6. Purpose of the disclosure

At my request Continuity or coordination of care Insurance, benefits, Medicaid, or payment Legal or personal business Transfer to another provider or service organization Other

Other purpose

7. Expiration

This authorization expires on the earlier of the date or event selected below. The expiration must be specific enough to determine when authorization ends.

On this date

When this event occurs

Ninety days after signature, if neither option above is completed.

8. Your rights and important information

Signing is voluntary. Harbor & Haven generally will not condition treatment, payment, enrollment, eligibility for benefits, or non-medical home-care services on signing this authorization, except when the law permits a specific exception.
You may revoke this authorization at any time by sending a written request to Harbor & Haven’s Privacy Officer at the address shown on this form. Revocation will not affect disclosures already made in reasonable reliance on this authorization or other action the law permits.
Information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by HIPAA. Federal or Virginia law may continue to protect certain records, including qualifying substance use disorder, HIV, genetic, or mental-health information.
You may request and receive a copy of this signed authorization. A copy, electronic image, or electronically signed version may be treated as valid to the extent allowed by law.
Harbor & Haven may verify identity, authority, recipient details, and delivery instructions before releasing records. Reasonable copying, labor, postage, or electronic-delivery charges may apply only when permitted by law and disclosed in advance.

9. Authorization and signature

I have read and understand this authorization. I authorize the disclosure described above. I understand the information to be released, the recipient, the purpose, the expiration, my right to revoke, and the possibility of redisclosure. I certify that the information I provided is accurate and that I am the individual or a person legally authorized to act for the individual.

Signature of individual or personal representative

Date

Printed name of signer

If representative, relationship to individual

Representative’s legal authority

Parent/guardian Health care agent Power of attorney Other

Authority documentation

Attached Already on file Not applicable

Witness signature, if required by Harbor & Haven policy

Date

10. Harbor & Haven administrative use

Clients leave this section blank.

Request received — date

Time

Identity and authority verified by

Records reviewed by

Disclosure completed — date

Method

Information withheld or request denied

No Yes — reason documented separately

Staff initials

Return completed forms to Harbor & Haven’s Privacy Officer at the mailing address above or through an approved secure delivery method (support@harborhavencare.org). Call (202) 834-7910 before sending sensitive information by ordinary email or fax to confirm current instructions.