Release of Information
Authorization to Use and Disclose Confidential Protected Health Information
As noted below the following are authorized to:
*
Disclose Information
Receive Information
Exchange Information
Regarding (Patient Name)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Name of Program/Person Authorized to Disclose/Receive/Exchange Information
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Fax Number
*
Please enter a valid fax number.
Email
*
Name of Program/Person Authorized to Receive/Disclose/Exchange Information
Address
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
Fax Number
Purpose of Disclosure- Select one
*
Continuity of Care
Disability Determination
Ongoing Treatment
Treatment Planning
Collateral
Other
Other specified information
Information to be Disclosed
*
Presence/Participation in Treatment
Intake Assessment
Diagnosis
Psychotherapy Session Notes
Treatment Plan or Summary
Crisis Assessment
Progress in Treatment
Psychological Testing
Information on Mental Illness and /or Treatment
Other, please specify below
Other specified information
Amount of Information to be Disclosed
*
Most recent episode of care
Previous three months
Other, specify
Other specified amount of information
I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon Creekside Counseling Group LLC receipt of the written revocation.
Select one of the following
*
This authorization will expire upon the termination of treatment & services at Creekside Counseling Group LLC.
This authorization will expire upon the disposition of the crisis assessment / crisis intervention & coordination of care .
This authorization will expire when (specify below)
This authorization will expire on (specify below)
Specifications (condition/date corresponding to above selection)
Signature
*
Name
*
First Name
Last Name
Title of Signee
*
Client
Guardian
Date signed
*
-
Month
-
Day
Year
Date
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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