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ATTACHMENT 7
HEPACO, INC.
CONSENT TO RELEASE OF MEDICAL
AND TREATMENT INFORMATION
I hereby freely and voluntarily authorize Dr./Clinic/Hospital ______________________ to
release to HEPACO any and all information, forms, notes and documents of any kind or nature regarding
my course of treatment in the rehabilitation program administered, directed or sponsored by the above
Dr./Clinic/Hospital. This authorization shall include allowing HEPACO to question and communicate
directly with employees of the above Dr./Clinic/Hospital regarding my course of treatment and to have
them bear witness to my course of treatment if legal proceedings should ever be involved.
Date Signature of Employee/Patient
Social Security Number
Date Signature of Witness
Document No. 804: Drug and Alcohol Abuse Policy
Revised December 2000 Attachment 7
