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!
Your Name*
I hereby authorize Britteny Asher Consulting and Associates to request, share and/or exchange information with the following individuals / service providers / agencies. Information to be shared is deemed relevant to collaborate and or provide services including evaluation, treatment and billing.
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
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.
I grant the above listed agencies / individuals permission to (choose one):

Disclose my complete health record including, but not limited to, diagnoses, test results, treatment, and billing records for all condition.Disclose my complete health record except for the following information- please mark items below.
Mark Any Items to be excluded:

Mental Health RecordsCommunicable disease including, but not limited to HIV and AIDSAlcohol / drug abuse treatment recordsGenetic InformationOther
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 (please list specific date or event to terminate agreement)
Name of person filling out this form *
Please type name. If you are the guardian, please know we require guardianship paperwork as well.
Signature of Individual or Guardian PLEASE NOTE ONLY THE LEGAL REPRESENTATIVE CAN SIGN THIS FORM*

Clear
Description of Personal Representative’s Authority to sign this form, if not the individual
MUST BE GAURDIAN
Date*

MonthDayYear
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