Release of Information

Mobile Counseling of New York LCSW, PLLC

14 Lafayette Sq. Suite 2300, Buffalo, NY 14203

Phone: (716) 302-4545

Fax: (716)453-4545
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your special authorization before we may use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed. Please read the information below carefully before signing this form.
SELECT INFORMATION TO BE DISCLOSED OR BEING REQUESTED
Health RecordsProgress NotesEducational RecordsLegal InformationDischarge SummaryDSS/ CPS RecordsAlcohol/ Substance Abuse RecordsInformation for transactions and assignment of benefits and claims
From Mobile Counseling of New York LCSW, PLLC (Name of Therapist):

Therapist First NameTherapist Last Name
Organization/ Individual Records Released to/from:
Who is receiving/sending the records
FROM: Mobile Counseling of New York LCSW, PLLC (clinical staff):

I hereby permit the use or disclosure of the above information to the person/organization/facility/program identified above. I understand that:

1. Only this information may be used and/or disclosed as a result of this authorization

2. A separate authorization is required to use or disclose confidential HIV-related information and certain alcohol and substance abuse records governed under 42 CFR, Part 2

3. This information is confidential and cannot legally be disclosed without my permission

4. If this information is disclosed to someone who is not required to comply with federal privacy regulations, then it may be re- disclosed and would no longer be protected.

5. I have the right to REVOKE (take back) this authorization at any time except to the extent that action has already been taken in reliance on this authorization. My revocation must be in writing. I do not have to sign this authorization and that my refusal to sign will not affect my ability to receive services from Mobile Counseling of New York LCSW, PLLC

I have read this form and all of my questions about this form have been answered. By signing below, I acknowledge that I have read and accept all of the above.
Client Name

First NameLast Name
If client is under the age of 18, name of parent/guardian responsible for signature

First NameLast Name
Client Email
example@example.com
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Patient or Personal Representative

Clear
Date

MonthDayYear
Date
Should be Empty:

SELECT INFORMATION TO BE DISCLOSED OR BEING REQUESTED