Authorization For Release Of Information

MOTIVATIONS COUNSELING PLLC - AUTHORIZATION FOR RELEASE OF INFORMATION
Client Name*
Date of Birth*

MonthDayYear
Parent/Guardian Name
Parent/Guardian Name (if client under 18 years old)
Select the Therapist you are authorizing to release/obtain information:*
Enter name of doctor, practitioner, practice authorized to release/obtain information to/from the Therapist *
Description of Information to be Disclosed
Diagnostic AssessmentPsychological EvaluationPsychiatric EvaluationTreatment Plan/RecommendationsProgress NotesTreatment Update/Summary
DiagnosisAttendance at SessionsTesting ResultsEducational InformationDischarge SummaryOther
Purpose
The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. If other purpose, please specify:
Revocation
I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to MOTIVATIONS COUNSELING PLLC at the above address. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
Expiration
Unless sooner revoked, this authorization expires on

MonthDayYear
Date
Conditions
I further understand that my MOTIVATIONS COUNSELING PLLC therapist will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:
N/A
Form of Disclosure
Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
Re-disclosure
Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. Other types of information may be re-disclosed by the recipient of the information in the following circumstances:
If applicable, please type the following: "I hereby release Motivations Counseling to disclose my substance abuse treatment information"
I will be given a copy of this authorization for my records upon request.
Signature of Client*

Clear
Date*

MonthDayYear
The undersigned attests to having legal authority to act on behalf of minor child/client, and hereby give(s) consent for release of information as stated above.
Signature of Parent, Guardian or Personal Representative

Clear
Date

MonthDayYear
Signature of Parent, Guardian or Personal Representative Date
If you are signing as a personal representative of an individual, please describe your authority to act for this individual power of attorney, etc
Check here if client/parent/guardian refuses to sign authorization.
Should be Empty:

MOTIVATIONS COUNSELING PLLC - AUTHORIZATION FOR RELEASE OF INFORMATION

Parent/Guardian Name

Description of Information to be Disclosed

Purpose

Revocation

Expiration

Conditions

Form of Disclosure

Re-disclosure