SSC Release of Information

Release of Information
Patient Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
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:*
Above, please enter anyone who, besides you, would you like us to communicate with about your healthcare: i.e., physician, psychiatrist, educator, family, therapist, legal personnel, individual seeking the information; please list the person(s) name and relationship(s) to you. I.e., "Jane Doe, Mother," or "Dr. Faisal Rafiq, Psychiatrist."
This authorization for release of information covers the period of healthcare from:*

All present, past, and future periodsOther
I authorize information to be released/exchanged regarding my:*

Mental health treatmentFinancial/Health Insurance informationWritten recordsOther
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)*

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Full Name of Patient*
Therapist Name*
Date Signed*

MonthDayYear
Date
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