Release of Information to External Party

Authorization to Release Confidential Information

www.boundlesshope.net - 813.219.8844
I hereby give my permission to Boundless Hope*, to release or request from a third party information contained in my medical record. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, sexual abuse treatment, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions, and that under law these records are classified as privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an expressed and informed consent. In addition, I understand that those records will not be released to entities other than those designated by myself or my personal representative or otherwise provided in federal law.
Client's Name*
Client Phone Number*
Please enter a valid phone number.
Client Email*
example@example.com
Client DOB*

MonthDayYear
Date
Therapist Name*

This information will be released/requested upon request between Boundless Hope* and (put N/A for any unused spaces):*

	Full Name of Third Party/Parties with Whom Boundless Hope* will Communicate to Request/Release Information:	Third Party Contact Information
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The type of information to be exchanged (check all that apply) To Be Released to Boundless Hope/Requested from Third Parties:*

Treatment PlansVerbal CommunicationsProgress NotesTreatment SummaryHealth/Medical/Academic Records (if applicable)Court DocumentsPsychological/Psychiatric EvaluationsNecessary Billing InformationScheduling/Canceling AppointmentsBio Psychosocial AssessmentsOther
**In the case of notes documenting or analyzing the contents of conversation during a private counseling session ("process notes"), such records may be protected from disclosure under the HPIAA Privacy Rule.
I understand that I have the right to withdraw my authorization at any time except to the extent that action has already been taken pursuant to the authorization. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Boundless Hope*. *
(initial)
I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign, and Boundless Hope* will not base my treatment or payment whether or not I provide authorization for the requested use or disclosure. I understand that I may inspect or copy the information to be disclosed, as provided in CFR164.524 (with reasonable charge). *
(initial)
I understand that information used or disclosed pursuant to this authorization may be subject tore-disclosure by the recipient of the information and is no longer protected by federal confidentiality laws or Boundless Hope*. Boundless Hope* will not be held liable for information disclosed to another party per the client’s request. *
(initial)
I understand that Boundless Hope* will release only the minimum amount of information necessary to fulfill a request. *
(initial)
This authorization shall expire when the client is discharged from the current episode of care (treatment has been completed, the client rejects/declines/drops out of treatment, is referred elsewhere, moves, or in the case of the client's death.) This agreement is subject to revocation in writing at any time.

*Boundless Hope is defined as any and all Boundless Hope clinical staff, whether 1099 contracted or W2 staff.
Signature Client / Next of Kin / Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Authorization to Release Confidential Information