Authorization for Release and Exchange of Confidential Information
This authorization complies with Ohio Revised Code §5122.31–§5122.32 and HIPAA. By completing this form, you authorize Sentirsi Counseling, LLC to release information as specified below.
SECTION 1 – EFFECTIVE DATE
Effective Date
*
SECTION 2 – CLIENT INFORMATION
Client Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
SECTION 3 – AUTHORIZED PROVIDER
Authorized Provider:Rachel Velishek, LPCC Sentirsi Counseling, LLC Columbus, Ohio
SECTION 4 – AUTHORIZED RECIPIENT
Name of Person Authorized to Receive Information
*
SECTION 5 – INFORMATION AUTHORIZED FOR RELEASE
I authorize the release and exchange of the following information (check all that apply):
*
Diagnosis
Treatment plans
Attendance and participation
Progress and clinical impressions
Care coordination and collateral communication
Other (please specify)
This authorization explicitly excludes psychotherapy notes, as defined under 45 CFR §164.501, which require separate written authorization.
SECTION 6 – PURPOSE OF DISCLOSURE
Purpose of Disclosure
SECTION 7 – METHOD OF DISCLOSURE
Method of Disclosure (select all that apply):
Verbal communication
Written records
Electronic communication (secure email or other electronic means)
SECTION 8 – EXPIRATION OF AUTHORIZATION
This authorization will expire:
One (1) year from the effective date
Upon termination of treatment
Upon written revocation by the client
Other (please specify)
If “Other,” please specify:
SECTION 9 – CLIENT RIGHTS & ACKNOWLEDGMENT
I understand that:
• I may revoke this authorization at any time by submitting written notice, except to the extent action has already been taken.
• Information disclosed may be subject to re-disclosure and may no longer be protected under HIPAA.
• My treatment, payment, enrollment, or eligibility for benefits is not conditioned upon signing this authorization.
SECTION 10 – CLIENT CONSENT
Client Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
SECTION 11 – PROVIDER SIGNATURE (Optional)
Provider Signature
Provider Name
Submit Authorization
Submit Authorization
Should be Empty: