Release of Information

Standard Authorization For Disclosure of Mental Health Treatment Information
I, (fill in name bellow), born on, (fill in DOB below)
Authorize Deaton & Deaton Counseling & Consulting to disclose to and/or obtain from (fill in name below) the following information:
Description of information to be Disclosed:

Assessment Diagnosis Psychosocial Evaluation Psychological Evaluation Psychiatric Evaluation Treatment Plan or Summary Current Treatment Update Medication Management Information Presence/Participation in Treatment Drug Screening Results/All labs Nursing/Medical Information
Purpose

Educational Information Discharge/Transfer Summary Continuing Care Plan Progress in Treatment Demographic Information Psychotherapy Notes (cannot be combined with any other disclosure)
This information may be used or disclosed in connection with mental health treatment, payment, or healthcare operations. If the purpose is other than as specified above, please specify:
Revocation

I understand that I have a right to revoke this authorization at any time by sending written notification to Deaton & Deaton Counseling & Consulting, LLC, at 215 Montgomery Avenue, Georgetown, KY 40324. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
Expiration

Unless sooner revoked, this authorization expires on the following date: one year from current date
Conditions

I further understand that Deaton & Deaton Counseling & Consulting, LLC will not condition my treatment on whether I give authorization for the requested disclosure.
Form of Discloser

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
Redisclosure

I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections.I will be given a copy of this authorization for my records.
Signature of Patient/Client

Clear
Client Signature Date

Month Day Year
Date
Signature of Parent, Guardian, or Personal Representative *Please specify your role as the Personal Rep*

Clear
Parent Signature Date

Month Day Year
Date
Personal Representative Capacity for Authorization:
Check here if patient/client refuses to sign authorization

Yes
Signature of Clinician

Clear
Clinician Signature Date

Month Day Year
Date
Should be Empty:

Standard Authorization For Disclosure of Mental Health Treatment Information

Revocation

Expiration

Conditions

Form of Discloser

Redisclosure