Release of Protected Health Information (PHI)

Sunbreak Therapy Services restricts the release of protected health information (PHI) to that permitted by patient confidentiality laws. According to HIPAA regulations, permitted reasons for release of PHI include treatment, payment, or healthcare operations, or as otherwise allowed by specific signed authorization from the patient or patient’s authorized personal representative.

The purpose of this Authorization for Release of PHI form is to provide patients the opportunity to permit the release and communication of PHI in the following ways:

I hereby authorize medical providers and personnel of Sunbreak Therapy Services to verbally discuss myprotected health information with the following individual(s):

Risk Acknowledgment: I understand that phone messages and emails may be viewed by third parties,including anyone with access to my voicemail or email account, and that unencrypted email may beintercepted. By consenting, I agree to hold Sunbreak Therapy Services harmless for any unauthorized access, use, or disclosure of my PHI sent via these methods.

Text messages may include appointment reminders, scheduling information, billing questions, and limitedprotected health information. Highly sensitive clinical information may be communicated by telephone or inperson at the discretion of Sunbreak Therapy Services.

Risk Acknowledgment: I understand that text messaging is not a secure or encrypted form of communication. Text messages may be viewed by third parties, including anyone with access to my mobile device or records from my cellular service provider. By consenting, I agree to hold Sunbreak Therapy Services harmless for any unauthorized use, disclosure, or access of PHI sent via text message.

• This authorization expires one year from the date of signing.
• My PHI that I agree to share may be sensitive. It may include diagnosis and treatment.
• I understand that I have the right to revoke this authorization, in writing, at any time.
• I understand that such a revocation is not effective to the extent that the clinic has relied on the use or disclosure of the protected health information.
• I understand the information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by state of federal law.
• This form is not valid unless signed and dated.