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 One Year from date signed unless written notice is given stating otherwise.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