Language
  • English (US)
  • PO Box 260116 Lakewood, CO 80228
    (303) 916-6929 | nibgoodman@gmail.com | nancygoodmanlcsw.com
    License #992896

  • Release of Information

  •  - -
    Pick a 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:

  • 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.

     

  •  - -
    Pick a Date
  • 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.

  • Clear
  •  / /
    Pick a Date
  • NATIONAL ASSOCIATION OF SOCIAL WORKERS

  • © Popovits & Robinson, P.C. 2013

  •  
  • Should be Empty: