Release of Information

Release of Information
Is there any person you would like your therapist and Silver Linings Counseling to be able to discuss any part of your treatment with? (Parent, school counselor, teacher, etc.).*

YesNo
I would like my therapist and Silver Linings Counseling to be able to:*

Exchange Information (Two-way communication)Disclose Information (One-way communication from Silver Linings Counseling to named person)Receive Information (One-way communication to Silver Linings Counseling from named person)
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name of Person Completing Form*

First NameLast Name
Relationship to Client*
Date

MonthDayYear
Date
Age
Name of Business/Person Authorized to Receive/Disclose/Exchange Information*
Address of Business/Person Authorized to Receive/Disclose/Exchange Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Business/Person Authorized to Receive/Disclose/Exchange Information*
Please enter a valid phone number.
Fax Number of Business/Person Authorized to Receive/Disclose/Exchange Information
Please enter a valid phone number.
Email of Business/Person Authorized to Receive/Disclose/Exchange Information
example@example.com
Purpose of Disclosure*

Continuity of CareOngoing TreatmentLegal PurposesEmploymentDisability DeterminationTreatment PlanningAcademic PurposesBilling/PaymentsSchedulingAttendanceOther
Other Purpose for Disclosure
Information to be Disclosed*

DiagnosisTreatment PlanProgress NotesAccount BalancePsychological Assessment ReportComplete RecordsInsurance IssuesBiopsychosocial AssessmentOther
Other Information to be Disclosed
Client/Guardian Signature

Clear
Email*
example@example.com
Re-Disclosure

I understand that this information may be protected by the Title 42 (Cod of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I understand that my Protected Health Information (PHI) that is used or disclosed under this authorization may be subject to re-disclosure by the recipient, and the privacy of my PHI may no longer be protected under these guidelines if they are not a health care provider covered by state or federal rules. The federak rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

Revocation of Authorization

I understand that this authorization is voluntary and may be revoked in writing at any time, except to the extent Silver Linings Counseling has already taken action upon it. I understand that if I revoke this authorization, I must do so in writing. Silver Linings Counseling will not condition treatment or payment based on this authorization or revocation of the authorization unless otherwise allowed by law.
Should be Empty: