Updated Release of Information

Release of Information

THE FAMILY GUIDANCE AND THERAPY CENTER
I,
[Insert Name of Patient/Client]
whose Date of Birth is:
authorize The Family Guidance and Therapy Center to disclose to and/or obtain from:
Name or Agency
(name of previous provider)
Phone Number
(name of previous provider)
Address
(name of previous provider)
I authorize release of the following information:
Description of Information to be Disclosed

(Patient/Client should initial each item to be disclosed)
Assessment

(initial if item is to be disclosed)
Diagnosis

(initial if item is to be disclosed)
Psychosocial Evaluation

(initial if item is to be disclosed)
Psychological Evaluation

(initial if item is to be disclosed)
Psychiatric Evaluation

(initial if item is to be disclosed)
Treatment Plan or Summary

(initial if item is to be disclosed)
Current Treatment Update

(initial if item is to be disclosed)
Medication Management Information

(initial if item is to be disclosed)
Presence/Participation in Treatment

(initial if item is to be disclosed)
Nursing/Medical Information

(initial if item is to be disclosed)
Educational Information

(initial if item is to be disclosed)
Discharge/Transfer Summary

(initial if item is to be disclosed)
Continuing Care Plan

(initial if item is to be disclosed)
Progress in Treatment

(initial if item is to be disclosed)
Demographic Information

(initial if item is to be disclosed)
Psychotherapy Notes* (*Cannot be combined with any other disclosure)

(initial if item is to be disclosed)
Other

(initial if item is to be disclosed)
Specifiy other:
Other

(initial if item is to be disclosed)
Specify other:
Purpose

This information may be used or disclosed in connection with mental health treatment, payment, or healthcare operations.
If the purpose is other than as specified above, please specify:
Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Jennifer Palmiotto at The Family Guidance and Therapy Center. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Expiration
Unless sooner revoked, this authorization expires on the following date:
or as otherwise indicated:
Conditions

I further understand that The Family Guidance and Therapy Center will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:
Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

Redisclosure

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.

I will be given a copy of this authorization for my records.
Signature of patient/client
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of parent, guardian or personal representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you are signing as a personal representative of an individual, please describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.).
Should be Empty:

Release of Information

Description of Information to be Disclosed