Updated Consent to Release Form

Consent to Release Private Health Information

Kentucky Counseling Center, LLC Fax-502-631-9660, Phone-855-591-0092
Client's name *

First Name Last Name
Birthday *

Month Day Year
Date
I consent for Kentucky Counseling Center, LLC and those representing this group to share my private health information with the following individuals and/or entities. KCC is permitted to send and receive information to and from those named below:
Name of the person(s) you want to release records to *
What company does this individual work for? *
What is your association with this person or company? (family, friend, attorney, school, etc) *
Please release the following documents: *

All medical records Treatment Plan Psychotherapy Notes Assessment Billing information
I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to Kentucky Counseling Center, LLC. I understand that a revocation is not valid to the extent that Kentucky Counseling Center, LLC has acted in reliance on such authorization. A copy of this release shall have the same force and effect as the original.

NOTICE TO RECEIVING PARTY: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure.

I understand that there is a potential for disclosure of this information by the recipient, and if that occurs, federal law may not protect the information.
Guardian's name with the legal authority to make medical decisions on behalf of the client if applicable *

First Name Last Name
Upload picture ID *

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Signature of client or guardian *

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Consent to Release Private Health Information