I authorize _______________ (print name of health care provider) (“Provider”);
To disclose Psychotherapy Notes;
To the following persons: Provident for the purpose of evaluating and administering claims, including assistance with return to work.
This authorization applies to medical records created by Provider and to any records that Provider received from any other source as long as the other source has not prohibited disclosure of those records.
“Psychotherapy Notes” means notes about me, recorded in any form, by a health care provider who is a mental health professional; that document or analyze the contents of conversation during a private, group, joint or family counseling session; and, that are separate from the rest of my medical record. “Psychotherapy Notes” does not mean: medication prescription and monitoring; counseling session start and stop times; the modes and frequencies of treatment furnished; results of clinical tests; and, any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
Information authorized for use or disclosure may include information which may indicate the presence of a communicable or non-communicable disease.
If I do not sign this authorization or if I alter or revoke it, Provident may not be able to evaluate my claim(s), which may lead to my claim(s) being denied. I may revoke this authorization at any time by sending written notice to the address above. I understand that revocation will not apply to any information that is requested prior to Provident receiving notice of revocation.
The privacy protections established by HIPPA may not apply to information disclosed under this authorization, but other privacy laws do apply. Information disclosed under this authorization may be redisclosed only as permitted or required by law, including state fraud reporting laws.
This authorization is valid for one (1) year from the date below, or the duration of my claim(s), whichever period is shorter. A copy of this authorization is as valid as the original.