Release of Information to Internal Party

AUTHORIZATION FOR EXCHANGE OF INFORMATION/RECORDS WITHIN BOUNDLESS HOPE
I, Client's Name* , Date of Birth* hereby give my permission to my Boundless Hope clinician, * and another Boundless Hope clinician, * to release/request the information selected below. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, sexual abuse treatment, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions, and that under law these records are classified as privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an expressed and informed consent. In addition, I understand that those records will not be released to entities other than those designated by myself or my personal representative or otherwise provided in federal law.
I give permission to the selected Boundless Hope clinicians to Release/Request the following information (check all that apply):*

Treatment PlansProgress NotesHealth/Medical Records (if applicable)Treatment SummaryPsychological/Psychiatric EvaluationsBio Psychosocial Evaluation/Assessment (if applicable)Verbal CommunicationOther, Please specify
* In the case of notes documenting or analyzing the contents of conversation during a private counseling session (“process notes”), such records may be protected from disclosure under the HIPAA Privacy Rule).
(INITIAL BELOW) I understand that I have the right to withdraw my authorization at any time except to the extent that action has already been taken pursuant to the authorization. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the selected Boundless Hope clinicians.*
INITIAL HERE ^
(INITIAL BELOW) I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign, and the selected Boundless Hope clinicians will not base my treatment or payment whether or not I provide authorization for the requested use or disclosure. I understand that I may inspect or copy the information to be disclosed, as provided in CFR164.524 (with reasonable charge).*
INITIAL HERE^
(INITIAL BELOW) I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of the information and is no longer protected by federal confidentiality laws or the selected Boundless Hope clinicians. The selected Boundless Hope clinicians will not be held liable for information disclosed to another party per the client’s request.*
INITIAL HERE^
(INITIAL BELOW) I understand that the selected Boundless Hope clinicians will release only the minimum amount of information necessary to fulfill a request.*
INITIAL HERE^
This authorization shall expire when the client is discharged from the current episode of care (treatment has been completed, the client rejects/declines/drops out of treatment, is referred elsewhere, moves, or in the case of the client's death This agreement is subject to revocation in writing at any time.
Signature Client/Guardian of Minor*

Clear
Date*

MonthDayYear
Date
Client Phone Number*
(000) 000-0000
Client Email Address*
example@example.com
Should be Empty:

AUTHORIZATION FOR EXCHANGE OF INFORMATION/RECORDS WITHIN BOUNDLESS HOPE