AGAPE - Release of Information

Release of Information

You must be 18 or older to complete this form.
This form, when completed and signed by you at the bottom of the page, authorizes the release of protected health information (PHI) from the client’s clinical record or other communication to the person(s) you designate. Your signature also indicates your acceptance of email as a possible means to receive your PHI. Please note email is an insecure method of electronic transmission that can be intercepted. Email accounts are subject to cybercriminal attack and any PHI sent or received could be viewed or stolen. You also understand that once your PHI is received electronically outside of AGAPE, it could be copied and redistributed, and may no longer be protected by HIPPA rules and regulations.
Client's Name*
(Include any alternate names under which records might be kept, e.g. maiden name.)
Client's Date of Birth*

MonthDayYear
Date
Release from:*
Name of agency, counselor, doctor, or other individual
Release to:*
Name, address, phone, and email of person/office to whom the information is to be released.
For the purpose of:
e.g. scheduling, billing, legal, continuity of care, etc.
Release the following:*

Dates of TreatmentTreatment Plan and UpdatesProgress NotesDescription of Progress in TreatmentContinuing Care PlanDischarge SummaryDischarge StatusEmergency InformationOther
This authorization shall remain in effect until:*

MonthDayYear
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You have the right to revoke this authorization, in writing, at any time by sending such written notification to your therapist's office address. However, your revocation will not be effective to the extent that he/she has acted in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. You also have the right to receive a copy of this authorization.

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I understand that my therapist generally may not require me to sign an authorization to receive psychological services unless the psychological services are provided to me for the purpose of creating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and is no longer protected by the HIPAA Privacy Rule.

I give this authorization voluntarily without coercion.
Signature of Client, Parent, or Legal Representative***

Clear
Relationship to client if signed by someone other than the client:
** If this authorization is signed by a legal representative of the client, a description of such representative's authority to act for the client must be on file in the client record.
Today's Date*

MonthDayYear
You can download a copy of the signed ROI on the next page.
Should be Empty: