* NOTICE: Information approved for disclosure based on this authorization may be protected by Federal Regulations (42 CFR Part 2,) which prohibit a recipient from making any further disclosure of alcohol or substance abuse treatment information unless expressly permitted by written authorization of the person to whom it pertains or their legal representative or otherwise permitted by 42 CFR Part 2. These Federal Regulations also restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client. 42 CFR Part 2 permits only limited disclosures regarding deceased clients when required by federal or state laws for the collection of vital statistics or an investigation into cause of death.
As the individual signing this Authorization, I understand:
I am giving my permission) Living Well Counseling and Support Services, LLC/Sherry Shuler, LPC and independent contractors to disclose/receive my confidential health records. That my signing this Authorization is voluntary. My health information is protected by federal HIPPA Privacy regulations. If the organization authorized to receive the Information is not a health plan, healthcare clearing house or health care provider covered by federal privacy regulations, the released Information may no longer be protected from further use or disclosure by federal privacy regulations and may be subject to re-disclosure by the recipient(s). Living Well Counseling and Support Services, LLC/Sherry Shuler, LPC and independent contractors may not condition treatment, payment, or enrollment on the signing of this Authorization. A photocopy of this Authorization is as valid as the original, and that I am entitled to a copy of this Authorization. Paper or electronic copies of my records may be used to facilitate disclosure of my information. I understand that I may see and receive a copy of the Information described on this Authorization if I request it in writing. I understand that I have the right to refuse to sign this Authorization.
This consent expires automatically one year from the date signed, unless otherwise indicated below: