Release of Information

Release of Information
By signing this form, I authorize LifeCyle Family Counseling (LCFC) to disclose information about myself or my minor child to the person or entity specified below.
Recipient of Disclosed Information:
The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services.
If the purpose is other than that as described above please specify:
Description of Information to be Disclosed

Click each box that you agree to:
Information to be Disclosed

AssessmentDiagnosesPsycho-social EvaluationPsychological EvaluationPsychiatric EvaluationTreatment Plan or SummaryCurrent Treatment UpdateMedication Management InformationPresence/Participation in TreatmentNursing/Medical InformationEducational InformationDischarge/Transfer SummaryContinuing Care PlanProgress in TreatmentDemographic InformationPsychotherapy Notes (CANNOT be combined with any other disclosure)Other
Expiration
This authorization will automatically expire on the day of discharge from treatment. If you wish to specify a different expiration date, please provide it below.
Expiration date

MonthDayYear
Date
Acknowledgements
- I understand that I have a right to revoke this authorization at any time by notifying LCFC verbally or in writing. I further understand that any revocation will not apply to information that has already been disclosed.
- Unless I have specifically requested that the disclosure be made in a certain format, LCFC reserves the right to disclose information as permitted by this authorization in any manner deemed to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
- I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections.
- If I request it, I will be given a copy of this form for my records.
Client Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of Parent or Legal Guardian If Different From Client

First NameLast Name
Date*

MonthDayYear
Date
Signature

Clear
Should be Empty:

Release of Information

Description of Information to be Disclosed

Expiration

Acknowledgements