Release of Information

Name

First NameMiddle NameLast Name

Previous/Maiden name if applicable

Date of Birth

Date

Discover Healing&#13;&#10;&#13;&#10;512 91st Ave Ste C&#13;&#10;Lake Stevens, WA, 98258&#13;&#10;&#13;&#10;828 2nd St. Ste H&#13;&#10;Mukilteo, WA, 98275

Discover Healing Clinicians may do the following with the below parties

Insurance Entity or Name of Person

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax

Please enter a valid phone number.Format: (000) 000-0000.

I authorize the release of any and all of the following medical or mental health information, as specified, which may be contained in my records. (Check all that apply, or check ALL, to agree to all options)

The purpose of this disclosure (Check all that apply, or check ALL, to agree to all options)

Is there other purposes for this disclosure?

I understand that my record may contain information regarding diagnosis or treatment of drug or alcohol abuse. I give my specific authorization for these records to be disclosed.(42 CFR, Part 2)

I understand that my records may contain information relating to mental health issues(per RCW 71.05.620). This authorization prohibits further use or disclosure of the information being released beyond the specific limits for this consent. I understand that information used or disclosed in keeping with this authorization may no longer be protected by Federal Law and could be used or re-disclosed by the receiving party. This consent is subject to my revocation at any time, except for information previously exchanged. To revoke this authorization, I must submit a written request to Discover Healing, DBA Discover Healing. I understand that I may refuse to sign this Authorization and that my refusal to sign may affect my ability to obtain treatment. Unless revoked earlier by me, this authorization shall expire either 30 days after the end of treatment or after all billing is complete whichever is later.

Signature of Client (If patient is 13 years of age or older, they must sign themselves)

Todays Date

Date

Signature of 2nd Client if applicable

Todays Date

Date

Parent / Guardian Signature

Todays Date

Date

Release of Information

Please Sign Below