Release of Confidential Records and Information

Release of Confidential Records and Information

BreakThrough Counseling Services, LLC.
I, First Name* Last Name*, hereby authorize the release of my own confidential patient health information (PHI).
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Permission is granted for: Provider Name* to:
Receive a written report from Third Party at the following address: Street Address   Address Line 2   City   State   Zip.
Provide a written report to Third Party at the following address:   Street Address   Address Line 2   City   State   Zip.
Exchange information verbally with Third Party at the following telephone number: Area Code   Phone Number
Check the type(s) of information being released/requested:*

Intake SummaryDischarge SummaryPsychological EvaluationSummary of TestingIndividualized Education PlanTreatment Report for Insurance AuthorizationAftercare PlanOther (Please specify below)
Other Types of Information
Use this space to explain any requests.
I have had explained to me and fully understand the request/authorization to release records and information, including the nature of records, their contents, and the consequences and implications of their release. This request is entirely voluntary on my part. I understand that I may take back this consent at any time within 180 days, except to extent that action based on this consent has already been taken. This consent will expire automatically after 180 days from the date on which it is signed, or upon fulfillment of the purpose stated above.
Signature of Client*

Clear
Name of Client*

First NameLast Name
Date

MonthDayYear
Date
Signature of Witness

Clear
Name of Witness

First NameLast Name
Witness Date

MonthDayYear
Date
Should be Empty: