Authorization for Release of Health Information

Authorization for Release of Health Information
Northlight Counseling Associates of Arizona
4121 E. Valley Auto Drive, #112, Mesa AZ 85206
Phone: (602) 285-9696 | Fax: (480) 632-0822
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
The above named person must indicate when this authorization is to expire:*

When information is receivedIn one yearIn six monthsIn three yearsOn date
Date of Birth*

MonthDayYear
Date
The person named above is or has been a patient of...

Name of Person, Provider, or Facility: Northight Counseling Associates of Arizona

Address: ___________________________________________________

Phone: 602-285-9696

Fax: _______________________________________________________
The patient/client above hereby authorizes [ add providers name] to... Request health information from Send health information to Discuss health information with .
Name of Person, Provider, or Facility Address
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Scope
All information regarding assessment, diagnosis, and treatment of patient’s condition, concern, or disease (specify):
All information regarding care received by patient between the dates of:
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Other information (specify):
Authorization
Printed Name of Patient or Authorized Representative

First NameLast Name
Signature of Patient or Authorized Representative

Clear
Date of Signature

MonthDayYear
Date
Signature of WitnessSignature

Clear
Date of Signature

MonthDayYear
Date
If not signed by the patient, indicate relationship of authorizing person to patient:

Parent or guardian of minor childGuardian or conservator of conserved patientBeneficiary or personal Representative of a deceased individual
Certain information is covered by additional protection and requires specific authorization. To authorize release or discussion of the following type of information, the person named above must initial and date each item. If an item is not initialed and dated, the information, if such information exists, cannot be released or discussed.
Alcohol or Drug Use/Abuse Treatment
From Date

MonthDayYear
Date
To Date

MonthDayYear
Date
Mental Health Treatment
From Date

MonthDayYear
Date
To Date

MonthDayYear
Date
HIV Status or Treatment
From Date

MonthDayYear
Date
To Date

MonthDayYear
Date
The above named person has the following rights:

• This authorization is effective for the above requested and authorized health care information only. You may ask for and receive a copy of this authorization form.

• This authorization will expire on the date you indicated above. Additionally, you may revoke this authorization at any time by submitting a written request to this clinic or caretaker. Your revocation will be honored except to the extent that is been acted upon in good faith while in force.

• You have the right to inspect the information you are authorizing to be re-released. This and other specific rights regarding the handling of your health information are outlined in our Privacy Practices document.

• The information you are authorizing to be released could be re-released or disclosed by the recipient. such additional disclosures or releases may not be prohibited by law. We are not responsible for the actions of others who may be provided with information released as a result of this authorization.

• You may refuse to sign this authorization. Such refusal will not affect your ability to obtain treatment except to the extent that the information being requested may assist your health care provider in determining appropriate treatment. Your refusal to sign this authorization will not affect your eligibility for ben
Should be Empty:

Authorization for Release of Health Information

Scope

Authorization