1936 William Street Fredericksburg, VA 22401
Phone: (540)455-4715 Fax: (540)371-5715
Website: http://www.kweberlcsw.com Email: email@example.com
I hereby authorize the communication of clinical information between Karin Elise Weber, LCSW, PLLC and the following individuals.
Please initial, date, and mark all that apply.
Note: Parent/legal guardian to initial if the client is a minor.
Communication may include direct verbal communication, clinical documentation including inpatient and outpatient treatment notes, discharge summaries, testing and laboratory results, and similar clinically relevant materials. I understand that I may withdraw this consent at any time by submitting a request in writing. Please note that once the requested information is disclosed pursuant to this Authorization, Karin Elise Weber, LCSW, PLLC will no longer have control over the information and there is a potential that it may be re-disclosed by the recipient and will no longer be protected by the privacy rules under the Health Insurance Portability and Accountability Act.
** This authorization for release of information is good for one year after date signed, until client (or parent/legal guardian if client is a minor) revokes authorization, or until client (or parent/legal guardian if client is a minor) is discharged from treatment (whichever precedes).