(A) Each request for information regarding a current or previous client shall be accompanied by an authorization for release of information, except as specified in sections 5119.27, 5119.28, and 5122.31 of the Revised Code.
(B) The authorization for release of information shall include, but not be limited to, the following:
(1) The full name of the client.
(2) Date of birth of the client.
(3) The specific information to be disclosed.
(4) The name of the person or entity disclosing the information.
(5) The name of the person or entity receiving the information.
(6) The date, event, or condition upon which the authorization shall expire.
(7) Statement that the consent is subject to revocation at any time except to the extent the provider or person who is to make the disclosure has already acted in reliance on it.
(8) The dated signature of the client or, as appropriate, a legally authorized agent and the agent's relationship to the client.
(9) For clients receiving addiction services treatment, the following statement:
"This information has been disclosed to you from records protected by federal confidentiality rules. 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 C.F.R. 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 information to criminally investigate or prosecute any alcohol or drug abuse client."
(C) If the client is a minor, the release of information shall either:
(1) Be signed by the client's parent or legal guardian;
(2) In the case of providers who are certified to provide AoD treatment services, be signed by the client and the client's parent or legal guardian; or,
(3) In the case of providers who are certified to provide AoD treatment services and minor client's providing consent to treatment pursuant to section 3719.012 of the Revised Code, the client shall sign the release of information.
(D) In the case of providers who are certified to provide AoD treatment services, when providing services to clients who are minors but who are not providing consent pursuant to section 3719.012 of the Revised code; the provider must either obtain the client's authorization to contact the client's parent or legal guardian or find the minor lacks in capacity to make a rational choice in accordance with 42 C.F.R. part 2.14(c)(2).