Authorization for Release of Confidential Information

Authorization for Release of Confidential Information

Red Road Counseling Services
Client Name *

First Name Last Name
Date of Birth *

Month Day Year
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 Code Phone Number
Address of Individual or Facility *

Street Address

Street Address Line 2

City State

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

Discharge or Treatment Summary Dates of Treatment Medical/Physical History Psychiatric Evaluation Social History Treatment Plans Medication History Progress Notes Verbal Communication Permission for my child to have therapeutic services provided by Red Road Counseling's providers at the above named school or facility Permission for my child to be picked up &/or dropped off by the above named individual for the purpose of therapeutic services. Entire Record
Dates of Treatment, if known:
The information will be obtained, used, or disclosed for the following purpose(s) only: *

Continuity of Therapeutic Services
- 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:

Month Day Year
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 *

Month Day Year
Date
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Red Road Counseling Services Representative Signature

Clear
Date

Month Day Year
Date
Should be Empty: