Release of Information

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
Full Legal Name *

First Name Middle Name Last Name
Client Date of Birth: *

Month Day Year
Date
Name of Parent/Guardian
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I hereby authorize Hope Counseling and Consulting to: *

Obtain Confidential Information From: Disclose Confidential Information To: Exchange Confidential Information With:
Name of the person or organization who is authorized to receive information: *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Fax Number

Area Code Phone Number
1. The purpose for which this information may be disclosed: *

Treatment Insurance Care Coordination
2. What information may be disclosed: *

Presence in Treatment Psychological Reports/Tests Appointment Information Progress in Treatment Diagnostic Assessment Discharge Summary Diagnosis/Prognosis Alcohol & Drug Abuse Records (Protected by Federal Confidentiality Rules 42 CFR Part 2 which prohibit any further disclosure unless further disclosure is expressly permitted or written authorization by the person to whom it pertains or as otherwise permitted by 42 CFR Part 2)
3. Requested Information Dates from: *

Month Day Year
Date
To: *

Month Day Year
Date
4. This authorization expires twelve (12) months from the date of my signature below.
5. I understand that:
- The federal Privacy Rule (HIPAA) does not protect the privacy of information if re-disclosed and therefore request that all information obtained be held strictly confidential and not be further released by the recipient . I intend this document to be a val id authorization conforming to all requirements of the Privacy Rule and state laws.
- I may revoke this consent at any time by completing a written Revocation of Release of Information Form . Revoking this authorization does not apply to information that al ready has been released under this authorization.
- I need not consent to the release of information in order to obtain services. I choose to do so willingly for the purpose(s) specified above.
- My signature below asserts and confirms my legal authority to sign on behalf of the minor.
Signature of Client or Authorized Representative *

Clear
Date *

Month Day Year
Date
Name of Witness *

First Name Middle Name Last Name
Relationship to Client *
Witness Signature *

Clear
Should be Empty:

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION