healingstreamsbehavioralhealth.com - Medical Records Release Request

Release of Information
Healing Stream Behavioral Health Services
I, patient name* (Patient Name), hereby authorize Healing Stream Behavioral Health Services to disclose and/or receive my protected health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
Person(s) or Organization Authorized to Receive/Exchange Information:
Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Information to Be Shared (check all that apply)

Other
Purpose of Disclosure

Other
This authorization allows communication by verbal, written, electronic, and telehealth means, including phone, email, secure messaging, and fax.
I understand that:
- This authorization is voluntary and may be revoked at any time in writing, except to the extent action has already been taken.
- This authorization will expire on: blanks or ☐ One (1) year from the date of signature.
- Information disclosed may no longer be protected by HIPAA once released to the recipient, unless otherwise required by law.
Signature
Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Release of Information