BAC Release of Information

BRITTENY ASHER CONSULTING
HIPPA Consent for Release Of Information
If you have any questions when filling out this form, please contact Britteny Asher Consulting, we are here to help!
Person Giving Consent to Release Information to Another *
You have the right to choose how your personal information is shared and used. By signing this form, you agree to allow Britteny Asher Consulting and our contracted clinician’s to request, share and/or exchange information with other people who you have engaged services from. These may be individuals, service providers or agencies who you have worked with in the past or who you are currently working with or plan to work with. You have the right to identify what information you agree to have shared with these entities and for how long information can be shared (e.g., when this consent ends).

You have the right to revoke your permission, at any time, by giving written notice that you want to revoke your consent to the person or organization named under “Who Can Britteny Asher Consulting request, share and/or exchange information with?

If you agree to allow Britteny Asher Consulting and our contracting clinician’s to request, share and/or exchange information with others, please list those individuals, service providers and/or agencies below.
Person or Agency approved to contact :*
Person or Agency you want BAC and Associates to be able to talk and share information with.
Their Relationship To You:*
How do you know this person or agency?
Their Phone Number*
Please enter a valid phone number.
Their Email Address:
example@example.com
Do you want to add another Person or Agency to this Release of Information??

YesNo
Person or Agency approved to contact :*
Person or Agency you want BAC and Associates to be able to talk and share information with.
Their Relationship To You:
How do you know this person or agency?
Their Phone Number*
Please enter a valid phone number.
Their Email Address:
example@example.com
Do you want to add another Person or Agency to this Release of Information??

YesNo
Person or Agency approved to contact :*
Person or Agency you want BAC and Associates to be able to talk and share information with.
Their Relationship To You:
How do you know this person or agency?
Their Phone Number*
Please enter a valid phone number.
Their Email Address:
example@example.com
Do you want to add another Person or Agency to this Release of Information??

YesNo
Person or Agency approved to contact :*
Person or Agency you want BAC and Associates to be able to talk and share information with.
Their Relationship To You:
How do you know this person or agency?
Their Phone Number*
Please enter a valid phone number.
Their Email Address:
example@example.com
Do you want to add another Person or Agency to this Release of Information??

YesNo
Person or Agency approved to contact :*
Person or Agency you want BAC and Associates to be able to talk and share information with.
Their Relationship To You:
How do you know this person or agency?
Their Phone Number*
Please enter a valid phone number.
Their Email Address:
example@example.com
Do you want to add another Person or Agency to this Release of Information?

YesNo
Choose One*

Disclose my complete health record including, but not limited to, diagnoses, test results, treatment, and billing records for all conditions.Disclose my health record except for the following information (please list items below)
Disclose my health record except for the following information:

Mental Health RecordsCommunicable diseases including, but not limited to, HIV and AIDSAlcohol/drug abuse treatment recordsGenetic InformationOther
I understand the records are protected under the federal and state confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time.

I also understand if I choose not to authorize disclosure of information needed for Britteny Asher Consulting to preform evaluations and or services, services provided by Britteny Asher Consulting may be limited, or refused.
This authorization to share my health information is valid:

IndefinitelyUntil Vocational Rehabilitation Services are ended (i.e., until individual moves into Long Term services)Other
Person providing consent to share information *
Please type name. If you are the guardian, please know we require guardianship paperwork as well.
Description of Personal Representative’s Authority to sign this form, if not the individual
MUST BE GAURDIAN
Signature of Individual or Guardian PLEASE NOTE ONLY THE LEGAL REPRESENTATIVE CAN SIGN THIS FORM*

Clear
This form will securely submitted to Britteny Asher Consulting.

If you would like a copy of this form, please select the "Preview PDF" button below and print from there. Thank you!
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BRITTENY ASHER CONSULTING

HIPPA Consent for Release Of Information