I (We) authorize Jodi Province Counseling Services, PLLC to release and disclose information from the clinical record of: Client's First Name* Client's Last Name* (Name of client/recipient of mental health services. Date of Birth: blank*
Information to be inspected and copied by: Name the Agency with whom we should share info.* at this address: List the Agencies address* .
Nature of information to be disclosed. (State specific nature of information to be disclosed.) blanks* . For the purposes of (State specific purpose of information to be disclosed) blank* .
Information to be released and/or exchanged includes any available substance use disorder/abuse/use or HIV/infectious disease information as verified by CLIENT INITIALS: YES: blanks NO: blank .
I understand I have the right to revoke this authorization, in writing, at any time by sending notice to Jodi Province Counseling Services, PLLC, office. I understand that a revocation is not valid to the extent that Jodi Province Counseling Services, PLLC office has acted in reliance on such authorization. This authorization is valid until: One year from today* (Date). A copy of this release shall have the same force and effect as the original. By signing below I acknowledge that I have been notified that release disclosure of information may occur with a consent unless it is an emergency of for other exceptions as detailed in the General Statues or in 445 CFR 164.512 of HIPAA.
Relationship to Client