When completed and signed by you, this form authorizes the release of protected health information from your clinical record to the doctor/facility/therapist you designate. It can also be used to authorize Integrative Behavioral Health & Healing Practice to obtain records from prior or current therapists, primary care providers, or any other pertinent practice or persons. This form complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

I authorize Integrative Behavioral Health & Healing Practice to Obtain OR Release OR Disclose information from/to the following providers listed below:

Obtain Records From:

Please complete all fields in this section

Release Records To:

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by a recipient of such information and it is possible that once disclosed, the privacy of the information may no longer be protected under federal medical privacy law. I understand that this authorization gives permission to release the information above which may include drug/alcohol abuse treatment (in compliance with 42 CFR Part 2), behavioral/mental health treatment, psychological or psychiatric impairments, HIV/AIDS, and other physical conditions. I understand that I may revoke or terminate this authorization at any time by submitting a written revocation to Integrative Behavioral Health & Healing Practice. A revocation will only apply to the information not yet released by the practice. This authorization will expire one year from the date signed, unless previously revoked. I understand that a fee may be charged for copying the protected health information. I further understand that I may request a copy of this signed authorization.

If the patient is a minor, lacks legal capacity or is unable to sign, an authorized personal representative may sign this form.