• Authorization for Release or Exchange of Protected Health Information (PHI)

  • I authorize my provider, {providersName} and/or his or her administrative and/or clinical staff to release and/or exchange the following information in regards Mental Health Records:


  • This information should be released to , received from and/or exchanged with:

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  • You have the right to revoke this authorization, in writing, at any time by sending such written notification to our office address.  However, your revocation will not be effective to the extent that we have taken action in reliance on the authorization of if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. 

    I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Patient Privacy Rule. 

  • Clear
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  • Should be Empty: