Release of Information

Authorization and Consent for the Release of Information
Jaci Varnell, MS, LPC-S

www.MyMckinneyCounselor.com
I hereby authorize exchange of information between Jaci Varnell, LPC-S and the following individual:
Name

First Name Last Name
Telephone Number

Area Code Phone Number
Agency (if applicable)
Information/Records to be released in regards to the following person:
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
The information/records released may consist of thefollowing:

Therapy notes Continuity of care Information as needed regarding therapeutic summary Insurance Credit card or other forms of payment
·       If I am signing as a parent or a guardian of a minor, I understand that the records released may contain references to my family and myself.

·       The authorization period will continue for one year from the date below.

·       I understand my right to confidentiality. I further understand that this consent form gives Jaci Varnell, LPC, permission to share confidential information about me and/or my child in the way described above.

·       Release of information is voluntary, I understand I have the right to refuse Jaci Varnell, LPC ‘s, request.

·       I understand I have the right to revoke this authorization in writing after signing this form.

·       I understand that all information will be treated as confidential.
Name of person signing and completing the form

First Name Last Name
Signature

Clear
Should be Empty:

Jaci Varnell, MS, LPC-S