Release of Information

Request/Authorization to Release Protected Health Information Form

DO YOU WISH TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM I - DR THOMAS THORSHEIM - MAY DISCUSS YOUR TREATMENT/MEDICAL CONDITION? IF SO, SPECIFY WHOM BELOW.
This form, when completed and signed by you, authorizes me and my office to release protected information about you from your clinical record to the person or people you designate. It also permits us to obtain information from those individuals and/or institutions you designate.
By signing, you attest that you have had explained to you and fully understand this request/authorization to release and obtain records and information, including the nature of the records, their contents, and the consequences and implications of their release or acquisition.
I your name*,
authorize my psychologist, Thomas Thorsheim, Ph.D., or his assistants, to release or obtain the following information pertaining to
enter patient name*
.
Select All That Apply*

Psychological EvaluationProgress NotesSummary of Clinical RecordOther
This information should only be released to or obtained from:(Select all that apply)*

My PhysicianMy AttorneyMy Previous TherapistFamily MemberOther
Name, address, and/or telephone number of person/people to whom information is to be released:
I am requesting that Dr. Thorsheim release this information for the following reasons: ('"at the request of the individual" is all that is required if you are my client and you do not have a more specific purpose")

AT THE REQUEST OF THE INDIVIDUAL - or - OTHER REASON*
This authorization shall remain in effect until you request otherwise or (in the event that you do not revoke it), it shall remain in effect for 2 years from date of signature.

You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that Dr. Thorsheim generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party.

I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.
Signature of Patient or Personal Representative:*

Clear
Enter your Name*

First NameLast Name
Date*

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Date
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Request/Authorization to Release Protected Health Information Form