Journey Therapy at The Barn Release of Information Consent

Release of Information Consent
Clients Full Name*
DOB*
Phone*
Address*

Address

Street Address Line 2

CityState

Zip
I, First Name Last Name , authorize (provider name) blank to (send) (receive) the following (to) (from) First Name Last Name First Name (provider name) Address: Street Address City State Zip p> p>
A SEPARATE AUTHORIZATION, AS DEFINED BY HIPAA, IS REQUIRED FOR PSYCHOTHERAPY NOTES.
Academic TestingBehavior ProgramsIntelligence testing resultsPersonality ProfilesPsychological reportsPsychological testing resultsService plansVocational testing resultsEntire record, except progress notesSummary reportsProgress reportsPsychological reportsOther
The above information will be used for the following purposes:

Planning appropriate treatment or programContinuing appropriate treatment or programDetermining eligibility for benefits or programUpdating filesCase reviewOther
I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 145 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient REcords, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these
guidelines if they are not a healthcare provider covered by state or federal rules.

I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states very, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information, I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.
Your relationship to client:*

SelfParent/Legal GuardianLegal RepresentativeOther
If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.
Client signature

Clear
Date*

MonthDayYear
Date
Parentguardianlegal representative if applicable signature

Clear
Date

MonthDayYear
Date
Witness if client is unable to sign signature

Clear
date

MonthDayYear
Date
Should be Empty:

Release of Information Consent

A SEPARATE AUTHORIZATION, AS DEFINED BY HIPAA, IS REQUIRED FOR PSYCHOTHERAPY NOTES.