CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

Client's name:*
Clinician's Email Address*
example@example.com
CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION
I, (name of client)*
DOB:*
authorize Improving Lives Counseling Services, Inc. and its duly authorized agents and employees to
Release To
(please initial if you want us to give information to the named entity)
Obtain From
(please initial if you want us to receive information to the named entity)
The following person or agency:*
For the Following Information (specific information requested):*
For the Following Purpose (specific need /reason):*
This release is only valid from (date):*

MonthDayYear
Date
To:
Treatment services are not contingent upon, or influenced by, the client’s decision to or not to permit the release of this information. The client’s consent shall be freely and voluntarily given. The information authorized for release may include records which may indicate the presence of a communicable or venereal disease which may include, but not limited to, diseases such as hepatitis, syphilis, gonorrhea, and AIDS.

Psychiatric Records: Oklahoma State Law (76 OS 1986, Section 19) provides that the psychological or psychiatric records may be provided to a patient only if the treating physician/practitioner consents to the release or upon request of a court order, issued by a court of competent jurisdiction. Therefore, The Agency will not release psychological or psychiatric records to patients, their guardians or agents (including attorneys) except with the consent of the treating physician/practitioner or upon the receipt of a court order, issued by a court of competent jurisdiction.

Drug/Alcohol Records: Confidentiality of drug/alcohol abuse records is protected by Federal Law. Federal Regulations (42 CFR Part 2) prohibit you from making further disclosure of this information unless disclosure is expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42CFR Part 2. A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMAITON IS NOT SUFFICIENT FOR THIS PURPOSE. The Federal rules restrict the use of the information to criminally investigate or prosecute any alcohol/drug patient.

I understand that my records are protected under the Federal and State Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g. probation, parole, etc).

I do not authorize further release to any other party. I do understand that The Agency and its staff, employees, officers, and directors cannot be responsible for the confidentiality disclosed after said information has been released pursuant to this authorization, and hereby, release them from any liability arising from such disclosure. I authorize this consent to release confidential information.
Signature

Clear
Date:

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Date
Legal Guardian Signature:

Clear
Date

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Staff/Witness Signature:

Clear
Date

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Should be Empty: