Obtain or Release PHI

Authorization to Obtain or Release Protected Mental Health Information
This is an authorization for Compass Counseling Services, LLC (CCS) to release, obtain, and/or exchange protected mental health information. By signing this form, confidential psychological and psychiatric information can be released to and/or discussed with the provider/agency listed below unless noted by exclusions or limitations.
Client Name *
Date of Birth *

Month Day Year
Date
I AUTHORIZE CCS to receive, obtain, and/or exchange confidential information with the following:
Person, Agency, or Contact Name *
Address *
Phone *
Fax
I AUTHORIZE that the following information be sent to CCS
I AUTHORIZE CCS to release the following information to the person/agency/contact named above *

Completion of forms/documents as requested by another agency/service: Diagnosis & Patient Status (Active or Discharged) Billing & Health Insurance Information Therapy/Counseling Assessment with Treatment Plan Therapy/Counseling Discharge Summary Psychiatric Evaluation with Treatment Plan Recent List of Psychiatric Medications Medication Progress Notes (which months?): Laboratory Test Results Psychological Evaluation/Testing Results Substance Treatment Record Other (specify)
Note any Exclusions or Limitations
Purpose:

Coordination of Care Treatment Information Legal Action Continued Treatment Insurance/Payment Other (specify):
I certify that my health information is being disclosed at my request or at the request of my personal representative. I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not dependent on my signing this authorization. By signing below, I acknowledge that I have read and understand this document and that I have voluntarily given CCS/my provider authorization to disclose my records. I understand that I may revoke this authorization at any time by providing a written notice to my provider. However, the revocation will not have an effect on any actions taken prior to the date my revocation is received.
I understand that my information may be redisclosed by the authorized person/organization receiving the information, and at that point, the information may no longer be protected under the terms of this agreement. I am also aware that utilizing my health and or my mental health records for legal purposes are left up to the interpretation by legal representatives and may or may not be beneficial to my legal case. This authorization will expire one year following the date signed unless revoked in writing.
Name of Client, Legal Guardian or Representative *
Signature of Client, Legal Guardian or Representative *

Clear
Today's Date *

Month Day Year
Date
Should be Empty:

Authorization to Obtain or Release Protected Mental Health Information