CSP Release of Information

Today's Date*

Date

Client's Name*

First NameLast Name

Client's Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Therapist Name*

I authorize my therapist to: (initial all that apply)
Receive information from organization or person below OR Send information to the organization or person below

Please put the name of the person or organization, Address, Phone number and email address*

PLEASE CHOOSE ONE OF THE FOLLOWING. Do not choose both.

1. INFORMATION TO BE DISCLOSED (please initial if it applies):

Entire mental health and/or substance abuse record

OR

2. DISCLOSE ONLY THE FOLLOWING TYPES OF INFORMATION BELOW: (please initial the information you want disclosed only)

Diagnosis

Assessment

Expected length of treatment

Name of new treatment provider

Medication information

Treatment recommendations

Attendance records only

Treatment plan or continuing care plan

Treatment progress report

Psychotherapy Notes

Other (please specify)

PURPOSE OF 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:

REVOCATION

I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of this authorization must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider has taken action in reliance upon it. And, I also understand that such revocation must be in writing, with a signature, and received by Provider at 7100 SW Hampton St, Suite 223, Tigard, OR 97223, to be effective. A copy may be sent via email to gethelp@counseling-pdx.com. Therapist shall not condition treatment upon Client signing this authorization. I have the right to refuse to sign this form. I understand that information used or disclosed in this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule, although applicable Oregon law may protect such information.

FORM OF DISCLOSURE

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.

This authorization shall remain valid until one year after termination of treatment or the date indicated here:

Date of Termination (Optional)

Signature of Client / Parent / Guardian / Conservator / Authorized Representative*

Name of Client / Parent / Guardian / Conservator / Authorized Representative*

First NameLast Name

Notice to Recipient of Information

This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. If the records are so protected, Federal Regulation (42 CFR Part 2) prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFE Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse member.

CSP Authorization to Release and Exchange Information