Authorization for Use and Disclosure of Protected Health Information
hereby authorize Ithemba Counseling to:
Initial Disclose information to Initial Obtain information from
Initials Exchange information with. I authorize the person or organization below to disclose information to Ithemba Counseling:
Name: blanks Organization: blank
Initial all items to be shared.
blanks School Information blank I.E.P.
blanks Clinical Reports blank Medical Reports
blanks Psychiatric Evaluation blank Psychological Reports
blanksDSHS Reports blank Other
Specific Authorization
blanks (Initial) DRUG/ALCOHOL I understand that my records may contain information, diagnosis, or treatment for drug or alcohol abuse. I give my specific authorization for records to be released (CFR 42, Part 2).field. blank________(Initial) STD/AIDS/HIV: I understand that my records contain information regarding testing, diagnosis, or treatment of STD/AIDS/HIV. I give my specific authorization for these records to be released (RCW 70.24.105).
REDISCLOSURE PROHIBITED: This information has been disclosed to you from records whose confidentiality is protected by state or federal law. These laws prohibit you from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by state law. A general authorization for the release of medical or other information in NOT sufficient for this purpose.
THIS AUTHORIZATION IS SUBJECT TO REVOCATION AT ANY TIME, UNLESS THE AGENCY HAS ALREADY DISCLOSED THIS INFORMATION IF NOT PREVIOUSLY REVOKED or IF ANOTHER DATE IS NOT INDICATED, THIS CONSENT WILL TERMINATE IN NINETY (90) DAYS FROM THE SIGNATURE DATE.