Authorization to Disclose and Obtain Protected Health Information

Children's Advocacy Center
Serving Bastrop, Lee & Fayette Counties
Authorization to Disclose and Obtain Protected Health Information
Client Name:

First NameLast Name
Client DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I authorize
to disclose and obtain Protected Health Information for the individual named above. This permission to disclose and obtain information is limited to communication with the following individual or entity:
Person/Organization Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Reason for disclosure:
Other:
What information can be disclosed? Complete the following by initialing your preference:
Effective Time Period: This authorization is valid until the closure of the therapeutic relationship, permission is withdrawn, or the following specific time frame (optional):
Date of expiration

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Right to Revoke: I understand that I can withdraw my permission at any time by submitting written notice stating my intent to revoke this authorization. I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.
Signature Authorization: I have read this form and agree to the uses and disclosures of the information as described. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
Client
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
IF CLIENT IS A MINOR CHILD:
Parent/Guardian

First NameLast Name
Parent/Guardian
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Stacey Helm, LPC-S, ASOTP, NCC Sarah Moreno, LPC, NCC - License #80546 LPC-S #62725, ASOTP
License #99836 Franco Weaver, LPC, NCC - License #81843 Brittney Sartor, LMSW - License #51814
Kelly Gilleland, PhD, LPC-S, LSOTP-S, NCC Matthew Robbins, LPC - License #93233 LPC-S License
#72661, LSOTP-S License #99469 Katie Gross, PhD, LPC-S - License #68505
Ashley Pattillo, LPC Associate - License #95503
Supervised by Stacey Helm, LPC-S License #62725
Should be Empty: