Consent to Release PHI Rev 8-2024

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Name of Client:* This field is required.

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Date of Birth:* This field is required.

Date

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Please Select Only One Option:* This field is required.

I authorize Genesis Counseling Center to release a copy of my records to the following person, provider or organization

I request the release of my complete healthrecord be sent to Genesis Counseling Center from the following provider oragency (fax: 757-838-2573)

I request only verbal communication regarding my health record with the following person

I request a copy of my records be released to myself for the following reason

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I authorize Genesis Counseling Center to release a copy of my records to the following person, provider, or organization:

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I request the release of my complete health record be sent to Genesis Counseling Center from the following provider or agency (fax: 757-838-2573):

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I request only verbal communication regarding my health record with the following person:

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I request a copy of my records be released to myself for the following reason:

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1. Name of Person, Provider or Agency:* This field is required.

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2. Name of Person, Provider or Agency:* This field is required.

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3. Name of Person, Provider or Agency:* This field is required.

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1. Phone Number:* This field is required.

Area Code

Phone Number

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2. Phone Number:* This field is required.

Area Code

Phone Number

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3. Phone Number:* This field is required.

Area Code

Phone Number

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1. Fax Number:* This field is required.

Area Code

Phone Number

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2. Fax Number:* This field is required.

Area Code

Phone Number

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3. Fax Number:* This field is required.

Area Code

Phone Number

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The purpose or need for this disclosure is:* This field is required.

Coordination of Care

Personal Use

Attorney

School

Other

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I understand the following:

This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
I understand that I may be denied services if I refuse to consent to disclosure for the purposes of treatment, payment, or healthcare operations. I will not be denied services if I refuse to authorize disclosure for other purposes.
I understand that I have the right to revoke this authorization, in writing, at any time except to the extent that action has been taken in reliance on it. Unless I revoke my authorization earlier, this authorization shall expire one year from the date of this authorization.
I understand that my substance use disorder records (if any) are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
A copy of this form will be saved in my chart at Genesis Counseling Center.

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Date, Event or Condition:

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Signature of Client or Personal Representative:* This field is required.

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Date:* This field is required.

Date

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Printed name of Client or personal representative and his or her relationship to Client:* This field is required.

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Client/Guardian Contact Phone Number:* This field is required.

Area Code

Phone Number

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Individuals requesting their own records will be charged a reasonable, cost-based fee for paper or electronic copies. Third parties requesting records (including attorneys) will be assessed a reasonable charge as permitted by Virginia law, including a search and handling fee not to exceed $20, $0.50 per page for up to 50 pages and $0.25 per page thereafter for paper for hard copies, $0.37 per page for up to 50 pages and $0.18 per page thereafter for paper for electronic copies, plus all postage and shipping costs (not to exceed a total of $150 for electronic copies) Genesis Counseling Center has 30 days to process this request. This fee must be paid in full prior to release. Revised: 8/27/2024