Release of Information

Release of Information
I (client name)   First Name   Last Name   , DOB   Date   hereby authorize:   First Name   Last Name
Street Address   Address Line 2   City   State   Zip
Area Code   Phone Number

To disclose/receive the following protected healthcare information to/from
Cheri McCormack Counseling Services, LLC
Information to be disclosed:

Discharge SummaryDiagnostic AssessmentMedical/Physical HistoryPsychological TestingLab ReportsPhysician OrdersTreatment PlanOn-going consultationsSchool RecordsSocial HistoryDrug and Alcohol Treatment InformationOther
I understand I may revoke this consent at any time except to the extent that action has already been taken in reliance hereon, and if not revoked sooner in writing, this consent will expire 365 days for the date signed. I understand that a copy of release is as good as original for disclosure purposes. I understand that this release or a copy of this released may be mailed/faxed to the appropriate recipients to gain information.
I give special permission to release information regarding:

Substance AbusePsychiatric/Mental HealthHIV information
I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.
The information will be used/disclosed for the following purposes:

Continuing careViewing onlyInsurance purposesPersonalLegal purposesOther
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

Cheri McCormack Counseling Services, LLC will not condition my treatment, payment, enrollment (if applicable) in a health plan or eligibility for benefits on whether I provide authorization for the requested health disclosure.

I understand that I have the right to refuse to sign this authorization.
Signature of Client

Clear
Date

MonthDayYear
Date
Signature of Client Personal Representative

Clear
Description of Personal Representative
Signature of Witness

Clear
Date

MonthDayYear
Date
Cheri McCormack Counseling Services, LLC

2005 Ironwood Parkway, Suite 210, Cd’A, ID 83814
Phone (208) 661-1495 Fax (208) 545-5222
Should be Empty:

Release of Information

Cheri McCormack Counseling Services, LLC