MICHAEL STEPHENS, PHD, LPC COUNSELING

Agency / Person Obtaining Information:

Michael Stephens, PHD, LPC

12320 Route 30, Unit 11

North Huntingdon, PA 15642

(412) 877-8011

contact@michaelstephensphd.com

I authorize the aforementioned persons/agency to use, disclose, and/or release exchange the following protected health infromation information (PHI) for the purpose of:

Continuity of Care, Treatment Planning, On-Site Consultation, Collaboration and Provision of Services, Emergency Contact Infoermation, Medication Info

Methods of Exchange:

Verbal, Copies, Written/Electronic, Fax

The following info will be released and/or exchanged (as needed):

Evals conducted by practice, Treatment Plan Reviews, Treatment Plan (most current), Clincial Summary of Progress, Medical History / Examinatino, Treatment Status, Discharge Summary, Two-Way Communication, Medication Info, Collaboration

I have the right to revoke this authorization, in writing, by sending written notification to you. I understand that a revocation is not effective to the extent that you have relied on my authorization to disclose protected health information. I understand that the information may be re-disclosed and no longer subject to protection. I understand that I may not revoke this authorization to the extent that Michael Stephens, PHD, LPC has already relied upon it. I understand that if I revoke this authorization, I must do so in writing to Michael Stephens, PHD, LPC. I have read this authorization, or had it explained to me, and I understand it's contents.

By signing this form, I understand that I have the right to inspect or copy the individually identified health information to be disclosed.