Authorization for Release of Confidential Information

Authorization for Release of Confidential Information

Red Road Counseling Services
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I hereby authorize Red Road Counseling Services, LLC to exchange my health information and/or to execute the following actions as described below with:*
Name of Individual or Facility
Phone Number of Individual or Facility*

Area CodePhone Number
Address of Individual or Facility*

Street Address

Street Address Line 2

CityState

Zip Code
The following specific information and/or action is authorized to be exchanged or executed:*

Discharge or Treatment SummaryDates of TreatmentMedical/Physical HistoryPsychiatric EvaluationSocial HistoryTreatment PlansMedication HistoryProgress NotesVerbal CommunicationPermission for my child to have therapeutic services provided by Red Road Counseling's providers at the above named school or facilityPermission for my child to be picked up &/or dropped off by the above named individual for the purpose of therapeutic services.Entire RecordOther
Dates of Treatment, if known:
The information will be obtained, used, or disclosed for the following purpose(s) only:*

Continuity of Therapeutic ServicesOther
- This authorization is voluntary and I may refuse to sign this authorization. I understand that if I do not sign this form, it will not keep me from getting treatment.
- The organization authorized to receive my information may not be required by federal privacy regulations to protect my health information. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality requirements.
- I release the entities listed above, their agents and employees from any liability in connection with the use or disclosure of the protected health information covered by this authorization. The entity authorized to disclose the information will not be compensated by the recipient for the disclosure, except for the cost of copying and mailing as authorized by law.
- I may revoke this authorization at any time, in writing. However, revocation will not apply to information already used or disclosed in response to this authorization, if already released. Unless revoked or otherwise indicated, this authorization will expire on the following date, not to exceed one year:
Authorization expires on:

MonthDayYear
Date
The information you authorize for release may include records which may indicate the presence of a communicable or non-communicable venereal disease which may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea, or the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS).
Client Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Red Road Counseling Services Representative Signature

Clear
Date

MonthDayYear
Date
Should be Empty: