RELEASE OF INFORMATION AUTHORIZATION

Hope Behavioral Health

24100 Chagrin Blvd., Suite 330, Beachwood, Ohio 44122

Phone: 800-642-4560, Fax: 216.245.6770

I,*

Printed name of adult client, minor child's parent and/or legal guardian

authorize Hope Behavioral Health, LLC's therapist and the individuals or organizations listed below to have reciprocal communication about the type of disclosure checked and initialed*

Name of individual and/or organization I authorize to have reciprocal communication with Hope Behavioral Health, LLC

Regarding the Treatment Services of:*

First and last name of client

Client date of birth

Date

Type of information to be disclosed. Please initial all for which permission is being given:

Mental Health Services: Treatment services, progress reports, diagnostic information, treatment services reports and/or summaries and recommendations for ongoing advocacy. (Please initial below if permission is granted)

Service Coordination with other outside agencies as needed to improve overall level of functioning. (Please initial below if permission is granted)

Mental Health Services: Treatment services, progress reports, diagnostic information, treatment services reports and/or summaries and recommendations for ongoing advocacy.

Initials of individual consenting

Service Coordination with other outside agencies as needed to improve overall level of functioning.

Initials of individual consenting

Mode of communication includes email, fax, mail, phone, and face-to-face.

Hope Behavioral Health, LLC understands that alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

All health and behavioral health information is confidential and also protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 & 164 and cannot be disclosed without the written consent of the client, unless otherwise provided for in the regulations. The client may revoke this consent, in writing, at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically.

This Release of Information shall be enforced from the date signed and throughout the duration of treatment but no longer than for six (6) months following termination of services unless terminated in writing prior to that date.

I have read, reviewed and understand Hope Behavioral Health, LLC’s Release of Information Authorization.

I give my consent by my electronic signature to follow:

Date*

Today's Date

Signature of Client, Parent, or Legal Guardian Granting Consent:

Typed name of individual giving consent:*

First NameLast Name

Relationship to Client