Spouse: blanks Age: blank Year Married: How many pregnancies: How many live births: Loss due to:
I hereby authorize Ginger Gray, LCSW and Abiding Hope Christian Counseling, to disclose the individually identifiable health information as described below, which may include psychotherapy notes. I understand that if I do not sign this form, federal and state law will prohibit Ms. Gray and her practice from releasing records regarding her treatment of me/my child to the designated Recipient. By accepting the records pursuant to this Authorization, the Recipient acknowledges that the protected health information covered by this release is confidential, privileged and protected by federal and state privacy statutes and regulations, and agrees that Ms. Gray’s release of the individually identifiable health information will continue to be protected by federal and state privacy statutes and regulations.
I intend for this Authorization to remain in full force and effect until I revoke it in writing. Further, it is my intent that a copy of this Authorization shall have the same effect as the original. I further understand that I may revoke this authorization at any time by notifying Ginger Gray, LCSW in writing at Abiding Hope Christian Counseling, 19115 FM 2252, Suite 12, San Antonio, TX 78266. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation