Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information
Regarding (Patient Name)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I authorize Creekside Counseling Group, LLC to:*

Release/send recordsReceive/request recordsExchange information (verbally or written letters)
for the following information:*

Intake AssessmentPresence/Participation in TreatmentDiagnosisPsychological TestingTreatment Plan or SummaryTermination NoteProgress NotesOther
Authorizated Third Party:

This information is authorized to be released to, received from, or exchanged with the following person or program:
Name of Person*

First NameLast Name
Name of Program or Company
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Fax Number*
If no fax number is available, type in (000)000-000
Email*
Relationship to Patient*
Purpose of Disclosure- Select one*

Continuity of CareOther, please specify:
Authorization Expiration:

I understand I may revoke this release of information at any time in writing, except to the extent that action has already been taken. Further release shall cease (except as allowed by applicable law) upon Creekside Counseling Group LLC receipt of the written revocation.
This authorization will expire:*

Upon the termination of treatment & services at Creekside Counseling Group LLC.On this specific date or when (event):
Signature*
Printed Name*

First NameLast Name
Title of Signee*

PatientParent/Guardian
Date signed*

MonthDayYear
NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.
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