Release of Information

PO Box 260116 Lakewood, CO 80228
(303) 916-6929 | nibgoodman@gmail.com | nancygoodmanlcsw.com
License #992896
Release of Information
Your Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
By completing this form, you are authorizing Nancy Goodman, LCSW to disclose and/or obtain from, the below information that you have initialed beside each item.

Please enter the business information for whom Nancy will obtain from or disclose to:
Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Please initial beside each item that you would like to be disclosed:*

AssessmentDiagnosisPsychosocial EvaluationPsychological EvaluationPsychiatric EvaluationTreatment Plan or SummaryCurrent Treatment UpdateMedication Management InformationPresence/Participation in TreatmentNursing/Medical InformationEducation InformationDischarge/Transfer SummaryContinuing Care PlanProgress in TreatmentDemographic InformationPsychotherapy Notes (cannot be combined with any other disclosure)Other
Purpose

The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services.

Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Nancy Goodman, LCSW at 12157 W. Cedar Dr., #200, Lakewood, Co 80228. 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 one year from the date of signature or as otherwise indicated

MonthDayYear
Date
Conditions: I further understand that Nancy Goodman, LCSW will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:
Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, I 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
Date*

MonthDayYear
Date
NATIONAL ASSOCIATION OF SOCIAL WORKERS
© Popovits & Robinson, P.C. 2013
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Release of Information

NATIONAL ASSOCIATION OF SOCIAL WORKERS