AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

Continuing Hope Counseling LLC

534 10th Ave P.O. Box 73536 Fairbanks, Alaska 99707

Phone (907) 451-8208 Fax (907) 451-8207
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
Client Full Legal Name*
Client Date of Birth*

MonthDayYear
Client Address
Name of Parent/Guardian*
I hereby authorize Continuing Hope Counseling, LLC to:*

Obtain Confidential Information From:Disclose Confidential Information To:Exchange Confidential Information With:
Name of Person or Entity Receiving Information: *
Phone #
Address
Fax
1. The purpose for which this information may be disclosed:*

TreatmentCare CoordinationInsuranceOther
2. What information may be disclosed:*

Presence in TreatmentAppointment InformationDiagnostic AssessmentPsychological Reports/TestsProgress in TreatmentDischarge SummaryDiagnosis/PrognosisAlcohol & Drug Abuse Records (Protected by Federal Confidentiality Rules42 CFR Part 2 which prohibit any further disclosure unless further disclosure is expressly permitted or written authorization by the person to whom it pertains or as otherwise permitted by 42 CFR Part 2).Other
3. Requested Information Dates Range: *

MonthDayYear
from:
MonthDayYear
to:
4.This authorization expires twelve (12) months from the date of my signature below.
5. I understand that:

The Federal Privacy Rule (HIPAA) does not protect the privacy of information if re-disclosed and therefore request that all information obtained be held strictly confidential and not be further released by the recipient. I intend this document to be a valid authorization conforming to all requirements of the Privacy Rule and state laws.

I may revoke this consent at any time by completing a written Revocation of Release of Information Form. Revoking this authorization does not apply to information that already has been released under this authorization.

I need not consent to the release of information in order to obtain services. I choose to do SO willingly for the purpose(s) specified above.

My signature below asserts and confirms my legal authority to sign on behalf of the minor.
Printed Name*
Relationship to Client*
Signature of Client or Authorized Representative*

Clear
Date*

MonthDayYear
Date
Should be Empty: