Link to YKHC Release Forms

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Authorization to Release Patient Psychotherapy Notes

Behavioral Health Services
P.O. Box 528 • Bethel, Alaska 99559
Phone: 907-543-6100 • Fax: 907-543-6159

This notice accompanies a disclosure of information concerning a client in alcohol/ drug abuse treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Authorization To Release Patient Behavioral Health Information

Behavioral Health Services
P.O. Box 528 • Bethel, Alaska 99559
Phone: 907-543-6100 • Fax: 907-543-6159

This notice accompanies a disclosure of information concerning a client in alcohol/ drug abuse treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Authorization To Release Human Resources Information

Human Resources Dept.
P.O. Box 528 • Bethel, Alaska 99559
Phone: 907-543-6060 • Fax: 907-543-6061

Authorization To Release Specific Patient Information

Health Information Services Dept.
P.O. Box 287, Suite 3016, Bethel, Alaska 99559
Phone: 907-543-6388 Fax: 907-543-6417

Authorization To Release Patient Health Information

Health Information Services Dept.
P.O. Box 287, Suite 3016 • Bethel, Alaska 99559
Phone: 907-543-6388 • Fax: 907-543-6417