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 and payment or as otherwise allowed by the specific signed authorization of the patient or authorized personal representative.

The purpose of the Release of PHI form is to provide our patients an opportunity to permit verbal release of PHI in the following two ways:

I: Permission to Verbally Discuss PHI with Family Members/Caregivers I hereby authorize medical providers and personnel of Sunbreak Therapy Services to discuss my protected health information with the following person(s):

II: Permission to Disclose PHI via phone/email: I hereby authorize medical Providers and personnel of Sunbreak Therapy Services to leave a detailed message containing PHI at the following phone number:

• 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.

When we send you an email, or you send us an email. The information that is sent is not encrypted.This means a third party may be able to access the information and read it sense it is transmitted overthe internet. In addition, once the email is received by you, someone may be able to access your emailaccount and read it.

By signing below, you acknowledge your recognition and understanding of the risk of communicatingyour health information via unencrypted email and hereby consent to receive such communicationsdespite those risks.

By signing below, you also acknowledge that you have the choice to receive communications via othermore secure means of communication such as by telephone. By signing below, you agree to holdSunbreak Therapy Services harmless for unauthorized use, disclose, or access of your protected healthinformation sent to the email address you provide.

Please initial one: