Release of Information

54 Hartford Tpke, Tolland, CT 06084

Tel (860) 837-0204 | Fax (860) 294-0240 | Hello@GrowingWellCounseling.com
Authorization for Release of Information

This release must be completed in full to be able to exchange, obtain, or release information.
As noted below the following are authorized to:

Disclose Information to Growing Well CounselingReceive Information from Growing Well CounselingExchange Information with Growing Well Counseling (to AND from)
Release of Information

Authorization to Use and Disclose Confidential Protected Health Information
Regarding (Client Name)

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Name of Practice/Provider Authorized to Disclose/Receive/Exchange Information
Health Care Provider Communicating with Growing Well Counseling
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax #
Please enter a valid phone number.
Purpose of Disclosure- Select one

Continuity of CareDisability DeterminationOngoing TreatmentTreatment PlanningCollaborationReferral to provider(s)Clinical Consultation
Information to be Disclosed

Attendance/Dates of TreatmentCrisis AssessmentLab tests including medication resultsPhysician's Orders/Medical NotesPregnancy Test resultsPrenatal Care ReceivedProgress in TreatmentPsychiatric EvaluationPsychological EvaluationInformation on Mental Health and /or Counseling TreatmentUrine TestingBrief Statement Regarding ProgressCurrent Medication ListOther, please specify below
Other specified information
Amount of Information to be Disclosed

Most recent episode of carePrevious three monthsOther, specify
Other specified amount of information
I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon Growing Well, LLC receipt of the written revocation.
Select one of the following

This authorization will expire upon the termination of treatment & services at Growing Well Counseling.This authorization will expire upon the disposition of the crisis assessment / crisis intervention & coordination of care .This authorization will expire when (specify below)This authorization will expire on (specify below)
Specifications (condition/date corresponding to above selection)
Signature
Relationship to client

Client/SelfGuardian
Date signed

MonthDayYear
Date
NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.
Should be Empty:

54 Hartford Tpke, Tolland, CT 06084

Authorization for Release of Information

Release of Information