Release of Information

Shelby Counseling Associates, PSC
12701 Townepark Way Suite 200, Louisville, KY 40243
Phone: 502-254-8880 Fax: 502-254-8870
SCA@ShelbyCounseling.com

Client Name *

First NameLast Name

Client Date of Birth *

Date

Last 4 of SSN

My Provider:

I hereby authorize and request my protected health information to include:*

Billing and schedulingCoordination of careMedical records request including psychotherapy notesOther (please list below)

Other:

I release my protected health information to the following individual or office (do not put SCA here):*

Name:

Address:

Phone:

Email:

Fax:

Authorization for Use & Disclosure of Protected Health Information

I understand that my protected health information may include sensitive details related to Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) infection, as well as records concerning alcohol and drug abuse treatment.

The confidentiality of these records, maintained by Shelby Counseling Associates, PSC, is protected by Federal law and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Additionally, Federal regulations (42 C.F.R. Part 2) prohibit recipients of this information from making further disclosures without the written authorization of the individual to whom the records pertain. A general authorization for the release of medical or psychiatric information is not sufficient for this purpose.

I acknowledge that if my protected health information is disclosed to an entity not required to comply with Federal Privacy Regulations, that information may be re-disclosed and may no longer be protected.

Revocation Rights

I have the right to revoke this authorization at any time.
My revocation must be submitted in writing via a letter to Shelby Counseling Associates, PSC at one of the addresses listed on this authorization form.
I understand that revocation does not apply retroactively, meaning any disclosures already made in reliance on my prior authorization cannot be undone.
Authorization Expiration
Unless revoked earlier, I understand that this authorization will expire 365 days from the date of signing.

Right to Refuse

I acknowledge that I may refuse to sign this authorization, and that Shelby Counseling Associates, PSC may not condition treatment on its completion, except where permitted under 45 C.F.R. §164.508(b)(4).

I certify that I have read, understand, and received a copy of this authorization. This authorization supersedes all previous versions.

Client Signature (Guardian if under 18)*

Name of signer*

First NameLast Name

Date of Signature *

Date