Authorization for exchange/release of info

Authorization for Release/Exchange of Information
This is a release for Mantra Mental Health, LLC Phone: 614-984-4394 Fax: 614-319-5618 4041 North High Street, Ste 300 H, Columbus, Ohio 43214
Client information
Date:*

MonthDayYear
Date
Client Name (Print):*
Client Date of Birth:*
If under 18, parent/guardian name:
Guardian/ parent Date of Birth (only fill if client is under 18):

MonthDayYear
Date
Mantra Mental Health, LLC is authorized to exchange information with:
Individual's name (who you are consenting to release information to if they are an individual):
Organization or entity you are consenting to release information to (provide the workplace of the person if they are another service provider such Ohio Health, Barb and Brad's Law Office, Job and Family Services of Franklin County, etc.)
Client's relationship to this person (Who is this person to you? such as: spouse, sister, previous therapist, primary care doctor, case manager, lawyer etc)
Department (n/a if unknown or not applicable):
Phone Number of the person or entity/organization you release information to:*
Fax Number of the person or entity/organization you release information to (leave blank if none):
Address of the person or entity/organization you release information to:
Is the purpose of this release to include this individual in your sessions (such as for family sessions or couples sessions)? *
If the purpose of this release is to include this individual in your sessions do you consent to this person being present in telehealth sessions? (n/a if not applicable)*
Is the purpose of this release is to refer you to other or additional services?*
Is the purpose of this exchange or release records to coordinate with another provider?*
Is the purpose of this exchange or release of records related to a legal case or disability hearing?*
Is the purpose of this exchange/release to authorize another individual to have access to billing/insurance information or to provide payment for sessions?*
Please check all that you consent to release to this individual or organization*

Psychiatric or psychotherapy progress notesPsychiatric or psychotherapy assessment or evaluationCase management notesAppointment attendanceMedications listHealth historyDiagnosis historyHealth informationVerbal communications (required if you're including an individual in your sessions OR if you would like providers to coordinate to provide you the most thorough care possible)Treatment methods (types of therapy or other care)Other
Please indicate if there is anything you do not want shared
When would you like this release to expire*

1 year (recommended)6 months3 monthsUpon completion of exchange of recordsOther
By signing this I understand that:

This authorization will remain effective until the completion of care unless otherwise specified (above).

I have the right to revoke this release through verbal or written consent
I understand that the primary purpose of this release is to best serve my mental health needs.

I understand that if this release is to include another individual in my sessions, it does not guarantee that this person will be able to attend every session and I'm required to give my therapist notice when possible if I'd like them to join our sessions.

I understand that my provider will not release information or documents to this individual above that are not essential to my care unless explicitly requested by the client.
Signature of individual or legal guardian (if client is under 18)/personal representative:*

Clear
Should be Empty:

Authorization for Release/Exchange of Information

Client information