• I (We) authorize Jodi Province Counseling Services, PLLC to release and disclose information from the clinical record of:  *   *   (Name of client/recipient of mental health services.    
    Date of Birth:     
    *

  • Information to be inspected and copied by: * at this address: * .

  • Nature of information to be disclosed. (State specific nature of information to be disclosed.) * . For the purposes of (State specific purpose of information to be disclosed) * .

  • 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: NO: .

  • 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: * (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.

  •  -  -
    Pick a Date
  • Clear
  •  -  -
    Pick a Date
  • Clear
  •  
  • Should be Empty: