SSC Release of Information

Patient Name

First NameLast Name

Patient's Date of Birth

Date

Please list anyone who would you like us to communicate with about your healthcare.

Please list the relationship(s) you have to the individual/group(s) above; i.e., family, physician, psychiatrist, educator, therapist, legal personnel, etc.

Please list the contact information (phone and/or email) for those listed above.

This authorization for release of information covers the period of healthcare from:

Other

I authorize information to be released/exchanged regarding my:

Other

By signing this form, I authorize South Shore Counseling and Psychological Services, P.C. and its associated Providers/Clinicians/Administrative Staff to use and disclose my protected health information (including records relating to mental health care) to the individual(s)/group(s) listed above.

This medical information may be used by the person(s) I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Signature of Patient (Parent/Guardian if under 18)

Full Name of Patient

Therapist Name

Date Signed

Date