Patient Forms

Notice of Privacy Practices

We are required by federal and state law to maintain the privacy of your medical information and to give you our Notice of Privacy Practices (this “Notice”) that describes our privacy practices, our legal duties and your rights concerning your medical information. Specifically, ASAC is required to follow the federal HIPAA Privacy and Security rules (which are collectively sometimes referred to as the HIPAA Final Omnibus Rule. ) As a federally funded substance abuse treatment program, ASAC is also required to follow the federal Substance Abuse Privacy Regulations, 42 CFR Part 2. In addition, ASAC follows Iowa law concerning mental health treatment and AIDS/HIV treatment information. Click here to view our full document.

Patient Request For Information

If you have received services with ASAC in the past and would like to request copies of documentation from your personal health record, please fill out the Patient Request For Information. If you are currently receiving services, please speak with your primary counselor.

This form can be mailed, faxed, e-mailed, or delivered in person to any ASAC Office. Please note that requests for information take up to 30 days to process.

Mail:
Area Substance Abuse Council
3601 16th Ave. SW
Cedar Rapids, IA 52404

Fax: (319) 390-4381
E-mail: info@asac.us

Consent to Release Information

For current or past patients who wish to have ASAC disclose information from your personal health record to an outside source (i.e., family member, medical professional, lawyer, probation officer), a consent to release information must be signed.  Please read the instructions on the first page of this document and fill out the ASAC Consent to Release with Instructions form in its entirety.

This form can be mailed, faxed, e-mailed, or delivered in person to any ASAC Office. Please note that requests for information take up to 30 days to process.

Mail:
Area Substance Abuse Council
3601 16th Ave. SW
Cedar Rapids, IA 52404

Fax: (319) 390-4381
E-mail: info@asac.us

on August 29 • by