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HIPAA Authorization To Release Information Form
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English (US)
Spanish (Latin America)
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Name
First Name
Last Name
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Date of Birth
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Date today
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age
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Date From
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Date To
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Allowed Purpose of Disclosure of Information
Indicate the purpose of disclosure (e.g. Collaroration of Care with My Health Care Provider,For Record Review, Etc.)
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Person Allowed to Disclose Information
Prefix
First Name
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Person Information is to Be Disclosed to
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Type of Medical Information to be disclosed
Psychological Tests
Psychological Evaluation
All Medical Records
Progress Notes
Medical Consultations
Consultation Report
Emergency Records
Medical History & Physical Exams
Imaging Reports
Laboratory & Pathology Reports
Other
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11
Other Information allowed to be disclosed
I give consent to the release of information pertaining to drugs and alcohol
I give consent to the release of my genetic information and family background information
I give consent to the release of information pertaining to mental health diagnosis or treatment.
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Consent for Services
This section is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start your evaluation or therapy services. Please review the information. If you have any questions, contact your Provider. THE PROCESS is collaborative where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. An Evaluation identifies needs and provides for recommendations. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit. IN-PERSON VISITS & SARS-CoV-2 ("COVID-19") When guidance from public health authorities allows and your Provider offers, you can meet in-person. If you attend therapy in-person, you understand: • You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html); • If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel, you will not be charged a late cancellation fee. • You must follow all safety protocols established by the practice, including: • Following the check-in procedure; • Washing or sanitizing your hands upon entering the practice; • Adhering to appropriate social distancing measures; • Wearing a mask, if required; • Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and • Telling your Provider if you or someone in your home tests positive for COVID-19. • Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask. TELEHEALTH SERVICES To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth: • Risks • Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards. • Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions. • Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services. • Benefits • Flexibility. You can attend therapy wherever is convenient for you. • Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness. • Recommendations • Make sure that other people cannot hear your conversation or see your screen during sessions. • Do not use video or audio to record your session unless you ask your Provider for their permission in advance. • Make sure to let your Provider know if you are not in your usual location before starting any telehealth session. COMMUNICATION You decide how to communicate with your Provider outside of your sessions. You have several options: • Texting/Email • Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.• Secure Communication • Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.• Social Media/Review Websites • If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy. • Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back. • If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.
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13
Terms and Conditions
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This field is required.
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Signature of Patient / Subject
Clear
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Date Signed
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Parent or Legally Authorized Representative
In case the subject is beyond the legal age of consent:
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Name of Parent or Guardian
First Name
Last Name
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Relationship to Subject
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Signature of Parent / Guardian
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Date Signed
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21
Terms and Conditions
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