Release of Information Form

Authorisation for Release/Exchange of Information

Safe & Sound Counselling: For Creative & Diverse Minds
Introduction

This form is intended to give therapists the authority to release specific information about a client to a third party. This form must be completed by the client and kept confidential and secure by the therapist. A copy will be provided to the client for their records.
Client Name *

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NDIS participant number (if applicable)
Client Statement
I authorise the practitioner named in this section (Ayna Hennessy from Safe and Sound Counselling) and the specified third-partylisted in the below section, to exchange the types of information listed below for the purpose of coordinating my care.
To Whom the Information is to be Released
Name of Third Party (psychiatrist, parent/billpayer, allied health practitioner, GP, support coordinator, plan manager, lawyer etc):*

First Name Last Name
Organisation*
Role*
Phone Number*
Email Address*
Types of Information to be Provided/Exchanged: (tick all that apply)*

Medical history and evaluationsMental health historyDevelopmental and/or social historyEducational recordsProgress notes, and treatment plans or session summaryFamily historyScreeningsNDIS PlanNDIS funding details, balance, supports and goals.Information relevant to NDIS reportsLetters to others involved in client' care.Booking and Billing Information (such as appointment details and Invoices)Background/History/Summary of Events
Other Personal Information you consent to being provided(please specify)
Other
Purposes for which Information will be Used (tick all that apply)*

Assessment and DiagnosisPlanning appropriate treatment or programContinuing appropriate treatment or programDetermining eligibility for benefits or programCase reviewUpdating filesCoordination of CareReferralInformation sharing regarding NDIS allocation of funds.Character ReferenceFactual information regarding client's attendance and progressNDIS funding and plan for supportsVictims Assist or other financial supports for victims of crime or domestic abuse.Administration for accounting/ reimbursements eg bookings, payments, receipts only.Legal MattersOther
Other
Delivery Method (Select appropriate option)*

Secure Email (Encrypted and/or Password-Protected)Secure Portal (Halaxy)Phone Conversation: I consent to the exchange of my personal health information via phone conversations conducted in a private and secure setting to maintain confidentialityLetterEmailAll of the above
Client Consent*

I understand that this information may be protected by the Privacy Act 1988 (Cth) and the Australian Privacy Principles.I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a healthcare provider covered by Australian state or federal rules.I acknowledge that administrative staff, such as a Receptionist/Secretary/Executive Assistant, may also access or handle this information for the purposes of facilitating the referral or coordination of care. These individuals are also bound by the same privacy and confidentiality obligations.I understand that I have a right to receive a copy of this authorisation. I understand that I have a right to refuse to sign this authorisation.I understand that this authorisation is voluntary, and I may revoke this consent at any time by providing written notice. After one year, this consent automatically expires unless otherwise specified in the Release Date Expiration Section below.
Expiry date for Exchange of Information

MonthDayYear
Date
Note: This Authority to Release Information must be completed by the client and the original copy kept on the client's file. The therapist must retain a copy of this form for their records.
Disclaimer: The information released through this form is subject to the provisions of the Privacy Act 1988 (Cth) and the Australian Privacy Principles. The therapist must ensure that the information released is relevant and necessary for the purpose for which it is being released. The therapist must also ensure that the third party receiving the information is bound by a duty of confidence to keep the information confidential and secure.
Client Signature*

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Client Name*

First NameLast Name
Date *

MonthDayYear
Date
Guardian Name (if client is a minor)

First NameLast Name
Guardian Signature (if client is a minor)

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Phone Number
Please enter a valid phone number.
Email
example@example.com
Today's Date

MonthDayYear
Date
Should be Empty:

Authorisation for Release/Exchange of Information