Anna Stephens Release Authorization

Anna Stephens, Counseling Intern
2039 Mecklenburg Highway
Mooresville, NC 28115
CLIENT RIGHTS AND HIPAA AUTHORIZATIONS
The following specifies your rights about this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time ("HIPAA").
1. Tell your counselor if you don't understand this authorization, and the counselor will explain it to you.
2. You have the right to revoke or cancel this authorization at any time, except: (a) to the extent information has already been shared based on this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in writing to your provider.
3. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment. If you refuse to sign this authorization, it may hinder our ability to bill certain parties on your behalf.
4. Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA. This includes information given to your church in the event that you request a scholarship or if the church is helping with billing needs. Once you give permission for that information to be given to the designated person at the church, it is beyond our control as to which staff or lay people will have access to that information.
5. If this office initiated this authorization, you must receive a copy of the signed authorization.
AUTHORIZATION FOR DISCLOSURE
Client's Full Name
Client's DOB

MonthDayYear
Date
Date Authorization Initiated

MonthDayYear
Date
Authorization Initiated By (name of client, provider or other)
Relationship to client:

Information to be Released

Other
Purpose of Disclosure:
Counselor(s) Authorized to Make the Disclosure: Anna Veazey
Person(s) Authorized to Receive the Disclosure
Name
Address
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Church Authorized to Receive the Disclosure (if applicable)(Note: This includes church staff and others who may handle church scholarships or billing)
Name
Address
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
This Authorization will expire on

MonthDayYear
Date
or upon the happening of the following event:
Authorization and Signature: I authorize the release of my confidential protected health information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.
Client Signature
Date

MonthDayYear
Date
Signature of Personal Representative
Relationship to Client (if applicable):
Should be Empty:

CLIENT RIGHTS AND HIPAA AUTHORIZATIONS

AUTHORIZATION FOR DISCLOSURE

Person(s) Authorized to Receive the Disclosure

Church Authorized to Receive the Disclosure (if applicable)(Note: This includes church staff and others who may handle church scholarships or billing)