This form when completed and signed by you, authorizes the release of protected health information from your clinical record to the doctor/facility/therapist you designate. This form complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards. Please note that a separate form is required per entity.

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.