AUTHORIZATION TO RELEASE, RECEIVE, OR EXCHANGE INFORMATION

Barb LoFrisco, PhD, LMHC, LMFT 14499 N. Dale Mabry Ste. 164 Phone: (813) 404-9215 Tampa, Florida 33618

RE:*

First NameLast Name

RE:*

DOB:*

Your records, which are property of Barb LoFrisco, PhD., are privileged and confidential. A signed authorization to release or exchange psychiatric and/or psychological information is valid according to Florida Statutes 394.4615, 490.0147, 397.501, 90.503, 381.004, 394.459 and Federal Regulation 42 CFR, Part 2.; 45 CFR 160-164. Your records will not be released without this waiver except under the following circumstances: In the event of a valid emergency, upon receipt of a Court Order, allegations of elder or child abuse, or upon receipt of a request which may be governed by other Florida Statutes, such as Worker’s Compensation, etc. When exchanging information in cases where the client is involved in treatment with other agencies and professionals this authorization may include verbal as well as written communication (to include clinical records). Please keep in mind that it is your responsibility to specify any information you do not want released.

I authorize Barb LoFrisco, PhD to:*

Exchange withRelease to

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

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Phone Number*

Area CodePhone Number

The following information:*

Clinical impressions and summary of treatment interventions

For the purpose of*

Treatment PlanningInformation for PhysicianInformation for Attorney

I have given my consent freely, voluntarily, and without coercion. Re-disclosure of this information without further written permission is prohibited by Federal Regulations, which provide for penalites if violated.

This consent will expire upon satisfaction of the need for disclosure; and 90 days past the end of treatment when Exchanging Information; and not to exceed 1 year after the date signed for Release of Information. I may revoke this authorization at any time providing I notify Barb LoFrisco, PhD, in writing to that effect. However, such revocation will have no effect on any action previously taken.

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DATE:*

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