Release of Information

As noted below the following are authorized to:

Client Full Name

First NameLast Name

Date of Birth

Date

Name of Program/Person Authorized to Disclose/Receive/Exchange Information

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax #

Please enter a valid phone number.Format: (000) 000-0000.

I authorize Mental Health Rescue LLC. to request and exchange confidential professional information, including personal, psychological, medical records and opinions.

Name of Program/Person Authorized to Receive/Disclose/Exchange Information

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number

Please enter a valid phone number.Format: (000) 000-0000.

Purpose of Disclosure- Select one

Information to be Disclosed

Other specified information

Amount of Information to be Disclosed

Other specified amount of information

I understand that I have no obligation whatsoever to disclose the requested information and that I may revoke this consent at any time by informing Mental Health Rescue LLC or the above named parties.

In consideration of this consent, I hereby releaseMental Health Rescue LLC and the above named parties from any and all liability arising therefrom.

I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon Mental Health Rescue LLC revocation.

Signature

Print Name that is Signed Above

Date signed

Date

NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.

Statement of Release Authorization to Request and/or Release Information