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:
Treatment Plan or Summary
Current Treatment Update
Medication Management Information
Presence/Participation in Treatment
Drug Screening Results/All labs
Continuing Care Plan
Progress in Treatment
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:
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.
Unless sooner revoked, this authorization expires on the following date: one year from current date
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.
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
Client Signature Date
Signature of Parent, Guardian, or Personal Representative *Please specify your role as the Personal Rep*
Parent Signature Date
Personal Representative Capacity for Authorization:
Check here if patient/client refuses to sign authorization
Signature of Clinician
Clinician Signature Date
Should be Empty: