Release of Information

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
Full Legal Name

First NameMiddle NameLast Name
Client Date of Birth:

MonthDayYear
Date
Name of Parent/Guardian
Address

Street Address

Street Address Line 2

CityState / 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 CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number

Area CodePhone Number
1. The purpose for which this information may be disclosed:

TreatmentInsuranceCare Coordination
2. What information may be disclosed:

Presence in TreatmentPsychological Reports/TestsAppointment InformationProgress in TreatmentDiagnostic AssessmentDischarge SummaryDiagnosis/PrognosisAlcohol & 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:

MonthDayYear
Date
To:

MonthDayYear
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 valid 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 already 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

MonthDayYear
Date
Name of Witness

First NameMiddle NameLast Name
Relationship to Client
Witness Signature

Clear
Should be Empty:

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION