___    A court order of appointment as the conservator or guardian of the individual (copy attached).

___    An individual who is the parent of an un-emancipated minor child may generally act as the child’s
Personal Representative (subject to state law exceptions).

___    Other:__________________________________________________.

___    A power of attorney for health care purposes, including the right to access Protected Health Information (copy attached).

[9]    Photocopy or Facsimile: A photocopy or facsimile of this signed authorization form shall be considered as valid as an original signed copy.

I have had the opportunity to review and understand the contents of this form. By signing this
              form, I am confirming that it accurately reflects my wishes.

[7]    Voluntary: I understand that I am under no obligation to sign this form. I acknowledge that I am voluntarily signing this form to release my health information to the party or parties that I have designated.

[8]    Purpose of Authorization: I am requesting that my Protected Health Information be
              disclosed for the following purposes (initial all that apply):

	_____Needs assessment and treatment planning    _____Legal     
	
	_____Coordination of treatment    _____Continuity of care     ____Billing/insurance payment

NOTICE TO RECEIVING AGENCY/PERSON:

This information is confidential, and you may not disclose any information unless the person consents. You are bound by Federal and Idaho law regarding confidentiality of Alcohol and Drug Abuse patient records; neither such records, nor information from such records, may be further disclosed without specific
authorization.

___________	__________________________     ____________________________    _________

 Date                 Individual Signature		       Witness			          	  Date
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Complete the following only if you are a Personal Representative signing the form on behalf of the individual:

If a Personal Representative executes this form on behalf of the individual, the Personal Representative warrants that he or she has authority to sign this form on the basis of: