Authorization for Release & Request Information

If you filled out the intake paperwork when your were treated, you will likely have signed a release for your primary care provider or other medical professional and do not need to complete this form.

I was informed of the information requested/and or released. I understand that treatment services are generally not contingent upon my decision concerning the signing of this release. This release is valid for one year unless noted on the release form. I have the right to revoke this authorization at any time by informing the above-named therapist in writing. However, my revocation will not be effective to the extent that my clinician has taken action 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. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of my information and no longer protected by the HIPAA Privacy Rule. If the authorization is signed by a personal representative of the client, a description of such representative’s authority to act for the client must be provided. This information is confidential and protected by HIPAA regulation and federal law. A photocopy of this completed form is considered as valid as the original.

If records are requested, please call the office once this form is submitted to confirm it has been received and arrange for record release.