Release of Information Form
Authorization and Acknowledgement
I hereby authorize the selected counselor (select below) at Counseling West Seattle, a licensed mental health counselor, to disclose and receive protected mental health diagnosis and treatment concerning me and information about me.
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Please select a counselor.
Alexa Harmon
Anna Maria Austin
Aubrey Hardesty
Colette Swenson
Elliot Grossman
Emily Rohrdanz
Eric Mulholland
Ernie McGarry
Holly Bains
Karen Coppock
Katherine Lincicum
Matthew Kirshman
Stacey Schmitt
Toni Napoli
Effective Date of Release (enter the date you wish this form to be active)
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date (optional)
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I understand that my records are protected under federal and state confidentiality and privacy regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it. This consent automatically expires 90 days after treatment ends unless a different date is specified herein.
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Yes, I understand.
Patient Information
Patient Full Name
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First Name
Middle Name
Last Name
Disclosure Release Information
Purpose or reason for disclosure and information release
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Name of Person(s) or Organization(s) receiving records.
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Method of Release (please list email, fax, or address for paper copies)
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Email and other forms of unencrypted electronic communication pose a security risk such that records may be intercepted, read, copied, or modified during delivery. By electing email disclosure, the client acknowledges and accepts the risks of sending PHI over unprotected communications (such as email). The client acknowledges that they have received this warning and agrees to release Counseling West Seattle of liability in the event such records are compromised as a part of this request.
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I acknowledge.
Signatures
Are you, the patient, 12 years of age or older?
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Yes
No
Client Signature
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Date
*
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Signature
Date
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: