This information is pertinent to the client's mental health, behavioral or academic needs as deemed by either agency. This information may contain copies of discharge summaries, clinical notes or diagnostic tests pertaining to the client's evaluation and treatment. This release may be requested for additional purposes or include additional information as specified below:
Collaboration of Treatment Plans and Services
The information shared may be written and/or verbal and it may be currently in existence and/or that which is made in the future. This information will only be shared with appropriate personnel on a need to know basis. This authorization is good for one year from the date signed. I understand I may revoke this authorization at any time by giving written notice to Integrative Counseling Solutions. I understand that any release made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to confidentiality.
I understand my healthcare and payment for my healthcare will not be affected by this authorization.
Specific Authorization for Release of Information Protected by State/Federal Law I specifically authorize the release of data and Information relating to: