• AUTHORIZATION TO RELEASE OF CONFIDENTIAL INFORMATION

  • Client's Name: Birth Date:   Pick a Date   
    I, , authorize, Wendy L. Whitmore M.S. LMFT , at TRUTH, HEALING & EVOLUTION 909-576-5431, to [release] [request] [share] (circle all that apply) confidential medical record information [to] [from] [with] (circle all that apply),
    of/from     

  • Specifically: All Clinical Records 
      Educational Evaluation
      Mental Health Info/Progress Notes Summary
      Drug/Alcohol tests & results

  • Other:

  • The information is needed for the purpose of adopting a more comprehensive and integrated approach to my health care and maintaining a continuity of care for this purpose only unless other wise permitted or required by law.

    This authorization may be revoked at any time by the client. Revoking of this authorization shall not cancel any prior action that has already transpired. If not revoked, it shall terminate the last day of the clinical treatment.

    A photocopy, facsimile or duplicate copy of this authorization shall be as valid as the original.

  • The person signing this consent has a right to receive a copy of it. My initials,indicate that I have received a copy of this authorization to release medical records.

  • I have read and understand the nature of this release. I understand that I may revoke it at any time. I release the executive director, therapists, employees and the above-named organization from any liability that may arise from this action whether or not foreseen at present. I understand that certain medical records (including any alcohol and drug abuse information**) may be protected by Federal Regulations. **Drug Abuse Office and Treatment Act of 1972 21 U.S.C. 1175; Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (42 U.S.C. 4582).

  • Pick a Date

       

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  • I do not give my mental health provider permission to contact my primary care physician, therapist or other type of provider.

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  • *PRIVACY ACT STATEMENT
    1. The authority for soliciting the information comes from 10 USC 3012
    2. The purpose for soliciting the information is to provide the therapist/counselor data to assist in counseling you are seeking.
    3. The information will be maintained under strict professional guidelines at the T.H.E. and until, by law, your records are released to be
    destroyed.
    4. Providing the information is voluntary. There will be no adverse effect on you for not furnishing the information other than that certain data
    might not otherwise be available to the counselor/therapist to enable him/her to provide you the most effective therapy.

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