Authorization to Disclose and Receive Health Information

Authorization to Disclose and Receive Health Information
Client's Name*

First NameLast Name
Client's Date of Birth*
I hereby authorize Mindful Counseling LLC to receive information from and disclose information to: *
Indicate the Individual or Organization's Name who Mindful Counseling will share with, or receive information from.
Phone Number*
Enter the phone number of the individual or organization that Mindful Counseling will share with or receive information from.
Email Address*
Fax Number
Enter the fax number of the individual or organization that Mindful Counseling will share with or receive information from.
Address*

Enter the address of the individual or organization that Mindful Counseling will share with or receive information from.

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize Mindful Counseling LLC to receive information from and disclose information for the purpose of: *
Information to be disclosed:*

Initial AssessmentProgress NoteMost Recent VisitPsychological EvalutionDischargeOther
Covering the period(s) from (date)*

MonthDayYear
From Date
to (date)*

MonthDayYear
To Date
I authorize the release of information to acquired immunodeficiency syndrome (AIDS) or human immunodeficiency VIRUS (HIV) infection or other sexually transmitted diseases:*

YesNo
I authorize the release of information to Behavioral health services/psychiatric care:*

YesNo
I authorize the release of information to treatment for alcohol and/or drug abuse:*

YesNo
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the agency privacy officer. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: * . If I fail to specify an expiration date, event or condition, this authorization will expire in six months from the date on which it was signed.
• I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

• I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign thisauthorization. I need not sign this form in order to obtain health care treatment.
Signature of Client*

Clear
Print Guardian or Legal Representative's Name, if Applicable
Signature of Parent, Guardian or Legal Representative

Clear
Prohibition of Re-Disclosure: Federal law (42) CFR Part 2 and state laws (NMSA 1978 “Section 24-1-9.5 (1966): NMSA 1978 Section32A-6-15 (1955); NMSA 1978 section 24-24A-6(1977) prohibit further disclosure of HIV/AIDS and other sexually transmitted diseases, and mental health and alcohol abuse and drug abuse information to any person or agency without securing another proper written authorization for that purpose, or as otherwise permitted by Federal regulations or state law.
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