Release of Information

Shelby Counseling Associates, PSC
12701 Townepark Way Suite 200, Louisville, KY 40243
30 Stonecrest Court Suite 103, Shelbyville, KY 40065
Phone: 502-254-8880 Fax: 502-254-8870
ShelbyCounselingPSC@gmail.com

Client Name *

First NameLast Name

Client Date of Birth *

Date

Last 4 of SSN

My Provider:

I hereby authorize and request my protected health information to include:*

Billing and schedulingCoordination of careMedical records request including psychotherapy notesOther (please list below)

Other:

I release my protected health information to the following individual or office (do not put SCA here):*

Name:

Address:

Phone:

Email:

Fax:

I understand that this information may include information relating to Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) infection.
The confidentiality of alcohol and drug abuse patient records maintained by Shelby Counseling Associates, PSC is protected by Federal law and regulations, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Federal regulations (42 C.F.R., Part 2) prohibit the receiver of this information from making any further disclosures of the same, except with the written authorization of the person to whom it pertains. A General Authorization for the release of medical/psychiatric information is not sufficient for this purpose.
I understand that if my protected health information is disclosed to someone who is not required to comply with the Federal Privacy Regulations, then such information may be re-disclosed and would no longer be protected.
I understand that I have a right to revoke the authorization at any time. My revocation must be in writing in a letter to Shelby Counseling Associates, PSC at either of the addresses listed on this authorization form. I am aware that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization.
Unless otherwise revoked, I understand that this authorization will expire three hundred and sixty-five days (365) from the date of this form.
I understand that I may refuse to sign this authorization and that Shelby Counseling Associates, PSC may not condition treatment on the completion of this authorization except as indicated in 45 C.F.R./164.508(b)(4).
I certify that I have read and received a copy of this authorization. This authorization supersedes any and all previous authorizations.

Client Signature (Guardian if under 18)*

Name of signer*

First NameLast Name

Date of Signature *

Date