Patient Forms

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