Release of Information Form

Matt Misuraca LMFT / Release of Information

* Clients Information
Client Name:
Date of Birth:

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Home Phone Number:
Please enter a valid phone number.
Mobile Number:
Please enter a valid phone number.
I hereby authorize MATT MISURACA, MA, LMFT to release and/or exchange written or verbal protected health information with: (this section must be complete for release to be valid. Records will be mailed only to the address provided on this release)

* Person/orginization Matt is to release information to
Name/Orginization:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Select which option ALL dates of treatment

All dates of TreatmentSpecific dates (please list in box below)
SPECIFIC RECORDS TO BE RELEASED (all selections may not exist for all clients. Requests must be specific.)

All treatment records for insurance reimbursementAttendance LetterClinical Treatment RecordsAll Administrative DocumentsAccounting / Billing RecordsOther Specific Record:
INFORMATION RELEASED FOR THE FOLLOWING PURPOSE

Continuation of CareLegal PurposesPersonal ReasonsInsurance ReimbursementOther

Scope	This authorization includes release of records generated during treatment/therapy. I understand my records may also contain information reqarding mental health issues and/or HIV/AIDS status.
Expiration	This release is valid for one year from the date of my signature below or until revoked by me.
Right to Revoke	I understand I have the right to revoke this authorization in writing, at any time, by sending written notification to Matt Misuraca, MA, LMFT. I further understand that revocation of the authorization does not apply to information that had already been released in reliance on the authorization.
Fees	Matt Misuraca, MA, LMFT requires prepayment for the requested copies in accordance with the allowable tees set forth in state and federal law.
Conditions	Matt Misuraca, MA, LMFT will not condition my treatment on whether I give authorization for the requested disclosure.
Form of Disclosure	Matt Misuraca, MA, LMFT reserves the right to disclose information as permitted by this authorization in any manner we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format, or electronically.
Redisclosure	Federal law prohibits the person or organization to which disclosure is made from making any further disclosure of this information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F. R. Part 2.
Contact Information	Matt Misuraca, MA, LMFT 7 4-133 El Paseo Suite 11 Palm Desert, CA 92260 (760)708-8253

Matt Misuraca, MA, LMFT, requires an original signature on this release. For your protection, Matt Misuraca, MA, LMFT, reserves the right to request a notarized signature when necessary to verify the identity of a client.

Client Name (please print):
Client Signature:

Clear
Date:

MonthDayYear
Date
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