Authorization and Request for Release of Information

Authorization and Request for Release of Information
Name*

First NameLast Name
Therapist Name*
Therapist Name*

Roy Eiermann, LCPCBrian McKenna, LCSWTerese Youngblood, LCSWColin Boland, LPCKathryn Krause, LCPCJanelle Otero, LCPCOther/UnknownRebecca Doyle, LCSW
I authorize EDGE Counseling Solutions, to disclose to / obtain from / discuss with
Name/Organization and Contact Information *
Disclosure Type:*

Full Disclosure (all items below)Limited Disclosure (select items below)
I authorize disclosure of the following information:

Assessment, Diagnosis and RecommendationsEducational (Attendance, Behavior, Testing)Discharge / Transfer SummaryMedical (Diagnosis, Treatment, Med Management)Drug Screen ResultsPsychological EvaluationTreatment Plan or SummaryPsychiatric EvaluationTreatment Plan UpdateOther (Specify)
Other
Purpose

I understand that the sharing of information may assist in providing high quality services by: Improving assessment and treatment planning, sharing information relevant to treatment, and when appropriate, coordinating treatment services.
If other purpose, please specify:
Revocation
I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to EDGE Counseling Solutions, Attn: Roy Eiermann. I further understand that revocation of the authorization is not effective to the extent that action has been taken in reliance on this authorization prior to revocation.
Expiration
Unless revoked sooner, this consent becomes effective upon the date that it is received and expires no later than one year from the date below.
Expiration Date (one year from the below date)

MonthDayYear
Date
Form of Disclosure
Unless I have specifically requested in writing that the disclosure be made in a certain format (e.g. in person, in writing, by phone), EDGE Counseling Solutions reserves the right to disclose information as permitted by this authorization in any manner deemed appropriate and consistent with applicable laws and best practices, including electronically.
Conditions
I understand that EDGE Counseling Solutions will not condition the services received on whether full authorization for the requested disclosure is authorized. I understand that I have the right to inspect and copy the information to be disclosed. I further understand that refusal to authorize the release of information specified above will prevent disclosure of such information to the organization / person identified above, which may result in not receiving the highest quality of services needed or requested.
Signature of Client*

Clear
Date*

MonthDayYear
Date
Signature of Parent, Guardian

Clear
Date

MonthDayYear
Date
Signature of Witness (All consents must include the signature of a witness who can attest to the identity of the client signing)

Clear
Date

MonthDayYear
Date
Additional Signature

Clear
Date

MonthDayYear
Date
www.edgecounselingsolutions.com
Should be Empty:

Authorization and Request for Release of Information

Revocation

Expiration

Form of Disclosure

Conditions