Release of Information

Beacon Psychology Services LLC

Authorization for Disclosure of PHI

Patient Name*

DOB*

Date Signed*

Date

I understand that my signature on this form is voluntary and that not signing will not affect the ability to receive treatment at this practice. I understand that this release will expire in 180 days, unless revoked by me which I have the right to do at any time. I understand that any revocation will not apply to any PHI that has already been released in reliance to this authorization and to PHI created expressly for disclosure to the person/entity listed below. I understand that the PHI disclosed may be subject to re- disclosure by the person/entity receiving it and no longer protected by federal privacy regulations except in the case of drug/alcohol treatment which must be clearly stamped "Do not re-disclose" and protected accordingly under 42 CFR part 2. I understand that any questions I have about the use or disclosure of this PHI can be directed to this practice at any time.

I give permission for Beacon Psychology Services to:

Type a question*

Release PHIObtain PHIExchange PHI

PHI to be disclosed includes the following:*

The purpose of the disclosure is to:*

Coordinate ServicesAid in Treatment PlanningType option 3

I authorize disclosure to the following person(s)/entity(ies):

Patient/Legal Guardian SIGNATURE*

Clear

Relationship to patient*

Patient/Legal Guardian PRINTED NAME*