HIPAA Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information
Patient's Name*

First NameLast Name
Patient’s Date of Birth*

MonthDayYear
Date
Last 4 Digits of Patient's Social Security Number*
Information about my treatment will be disclosed by the following:
Christi Kersten, MA, LPC

Alaska:

Ardent Grace Counseling and Teletherapy, LLC

8165 Grant St.

Juneau, AK 99801

or

Texas:

TeleKoinonia, LLC

260 LCR 235

Mexia, TX 76667

Email: therapist@ckerstenlpc.com

Phone: (254) 271-0055

Fax: (254) 477-7023

Web: www.ckerstenlpc.com
Name of Provider, Program or Person(s) Authorized to Receive Protected Health Information:
Name of Recipient*

First NameLast Name
Provider Type or Relationship*
Recipient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient's Email *
example@example.com
Recipient's Phone Number*
Please enter a valid phone number.
Recipient's Fax Number (If Applicable)
Please enter a valid phone number.
Purpose of Disclosure (One or More)*

ReferralProvider ConsultationTreatment PlanningCoordination of CareDisability DeterminationOther
Description of "Other"
Information that I do NOT want to be disclosed (If Applicable):
Duration*

Care from intake through currentCare from intake through discharge3 months ago through current6 months ago through current12 months ago through current
Date*

MonthDayYear
Date
Conditions of Disclosure*

I understand this authorization remains in effect until the date of expiration, one year from the date I provide my signature.
I understand this authorization may be withdrawn any time in writing by me (except to the extent that action has already been taken). Further release shall cease except as allowed or required by law upon Christi Kersten, MA, LPC receipt of the written revocation.
My information will only be released to the party specified above for the purposes listed, except as required by law.
Signature*

Clear
Name of Signer*

First NameLast Name
Relationship*

SelfGuardianPower of Attorney
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.
Should be Empty:

Release of Information

Information about my treatment will be disclosed by the following:

Name of Provider, Program or Person(s) Authorized to Receive Protected Health Information: