HIPAA Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information
As noted below Christi Kersten, MA, LPC is authorized to: *

Disclose Information Receive Information Exchange Information
Regarding (Client Name) *

First Name Middle Name Last Name
Client's Date of Birth *

Month Day Year
Date
Christi Kersten, MA, LPC

260 LCR 235

Mexia, TX 7666

Email: therapist@ckerstenlpc.com

Phone: (254) 271-0055

Fax: (254) 477-7023

Web: www.ckerstenlpc.com
Name of Program/Person Authorized to Receive/Disclose/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 phone number.
Purpose of Disclosure- Select one *

Continuity of Care Disability Determination Ongoing Treatment Treatment Planning Any/All
Information to be Disclosed *

Attendance Crisis Assessment Lab tests including medication results Physician's Orders/Medical Notes Pregnancy Test results Progress in Treatment Psychiatric Evaluation Psychological Evaluation Information on Mental Illness and /or Treatment Urine Testing 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
Select one of the following *

This authorization will expire upon the termination of treatment & services 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)
*

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 I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken).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 Christi Kersten, MA, LPC receipt of the written revocation.
Signature *

Clear
Name of Signer *

First Name Last Name
Relationship *

Self Guardian
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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