I,
Name
*
First Name
Last Name
do hereby authorize New Vision Counseling Center to
Release
Receive
Exchange
Information Concerning (Name and DOB of Client)
To
From
With
Individual/Organization name and contact information (number, address, etc.)
Please select all that apply:
Treatment Progress
Treatment Planning
Medical Treatment
Reimbursement for Treatment
Psychiatric Evaluation
Social History
Treatment Summary
Diagnosis
Child Custody/Visitation
Comptency to Stand Trial
I understand that unless otherwise limited by state or federal regulations, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time by giving written notice to New Vision Counseling Center, LLC. If no prior notice of revocation is received, this consent will expire automatically two (2) years after the date indicated thereon. I further understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy rule.
I have read, or had read to me, the above and understand the contents.
*
Yes
Select only one option
*
I authorize this information to be faxed to the party indicated above and understand the limits of confidentially which doing so creates.
I have read and recived the ROI; however, at this time I do not have anyone I wish to release information to. I am aware that I can make changes as necessary and at anytime by completing this form.
By entering your name you acknowledgement completion of this form.
*
First Name
Last Name
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