Voluntary Authorization for Release of Information

Voluntary Authorization for Release of Information
Patient Authorization*
Please check all boxes that apply*

to DISCLOSE (release) Protected Health Information (PHI) to...to OBTAIN (receive) PHI from...to EXCHANGE PHI with...
* If we are releasing/obtaining or exchanging records with someone outside the practice, please insert their name, contact information and fax number below. *

* If we are releasing records within the practice, (one Healing Grace therapist to another Healing Grace therapist), please choose which therapist from the drop down bars below or choose OTHER and insert name.*

*This allows Healing Grace and/or your therapist to release protected information or talk to another person and/or organization about your care. Please note: Psychotherapy notes will not be released without a formal court ordered subpoena.
Client Name*

First NameLast Name
Release records FROM Outside HGCC (OTHER) or HGCC Therapist name:
Choose Therapist
Insert Name of OTHER Person or Organization
Contact Number

Area CodePhone Number
Fax Number*

Area CodeFax Number
Release records TO OTHER or Therapist Name:
Choose Therapist
Release records TO Organization name or Therapist not listed:
Contact Number

Area CodePhone Number
Fax Number*

Area CodeFax Number
Requested Dates of Service to release:

AllOther
Disclosure Scope for PHI Release:

ALL Medical RecordsStudent/School Records/ReportsPsychiatric Evaluation/Testing ReportHospital Admission/Discharge SummaryPsychosocial EvaluationContinuing Care PlanPsychological EvaluationTreatment Plan or SummaryMedication RecordsPsychotherapy NotesBilling RecordsPresence/Participation in TreatmentOther
Purpose or need for this information is:

MedicalLegalInsurancePersonalOther
Revocation

I understand that I have a right to revoke this authorization, in writing at any time by sending written notification to Healing Grace Counseling Center at 1272 NE Windsor Dr., Lee's Summit, MO 64086. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
Expiration
Conditions

I further understand that Healing Grace will not condition my treatment on whether I give authorization for the requested disclosure.
Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including but not limited to, verbally, in paper format or electronically.

Redisclosure

I understand there is a the potential the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protect health information will no longer be protected by HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections.
My signature below acknowledges that I have read, understand and voluntarily authorize the release of my Protected Health Information, (PHI).
Today's Date*

MonthDayYear
Date
Signature of Patient*

Clear
Signature of Parent, Guardian or Personal Representative

Clear
Printed Name of Signer:*
If you are signing as a personal representative of an individual, please describe your authority to act for this individual in the box below (ie. power of attorney, healthcare surrogate, parent, etc.)
Relationship*
Should be Empty: