Release of Information Form

Authorization for Release of Information

Disclosure of Protected Health Information
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Email
Enter your email address to receive a form submission confirmation email.
Does the patient have a guardian or legal representative?*

YesNo
Name of Guardian or Legal Representative*

First NameLast Name
Relationship to Patient*

Parent or guardian of unemancipated minorCourt appointed guardianExecutor or administrator of decedent's estatePower of Attorney
Which IHCC program should this release be sent to?*

Counseling CenterTesting CenterService CoordinationThe Learning CenterSupported Living
Purpose for Information Release*
Coordination of Care(Default entry is Coordination of Care. Add additional details as needed)
Type Information to be released (select all that apply)*

Comprehensive Diagnostic AssessmentNeuropsychological/Psychological EvalTreatment PlanHabilitative Intervention AssessmentImplementation PlanSIB-RMedical Social Developmental Assess.Communication regarding treatment and progressIEP and Eligibility ReportTherapy Plans and EvaluationsMedical Evaluations (WCC, Annual Physical, etc)Special Medical Needs formBilling RecordsOther
This will include the following confidential information relating to (if applicable):*

HIV/AIDS infectionDrug/Alcohol abusePsychotherapy recordsPsychotherapy notesNot Applicable / I do not authorize
Release Information to and from the Following
Name of organization*
Enter 'None' if releasing to/from an individual
Name of Individual

First NameLast Name
Please enter as much infornation about the organization or individual as you can.
Phone Number
Fax Number
Email Address
Physical Address

Street Address

Street Address Line 2

CityState

Zip Code
Current Date

MonthDayYear
Date
Default expire date
Default Expiration Date (365 days)

MonthDayYear
Set Expiration Date*

MonthDayYear
Up to a maximum of 365 days
Change expiration date to less than 365 days
Terms of Consent

1) THIS AUTHORIZATION IS VOLUNTARY AND I MAY REFUSE TO SIGN THIS AUTHORIZATION WITHOUT AFFECTING MY HEALTH CARE OR THE PAYMENT FOR MY HEALTH CARE
2) I have the right to request a copy of this form after I sign it as well as inspect or copy any information to be used and/or disclosed under this authorization (if allowed by state and federal law. See 45 CFR § 164.524).
3) I may revoke this authorization at any time by notifying Innovative Health Care Concepts, Inc. in writing as set forth in the Notice of Privacy Practices. However, it will not affect any actions taken before the revocation was received or actions taken in reliance thereon, or if the authorization was obtained as a condition of obtaining insurance coverage and other applicable law provides the insurer with the right to contest a claim under the policy.
4) Innovative Health Care Concepts, Inc. agrees to maintain the confidentiality of my protected health information; however, if the person or organization authorized to receive the information is not a health plan, health care clearinghouse or healthcare provider, federal law (HIPAA) requires me to be advised that information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by HIPAA rules.
5) I understand that Innovative Health Care Concepts will not use or disclose my information for marketing purposes, regardless of any compensation, without my prior consent, and that I am not giving such consent at this time.
Signature*

Clear
Signature of Patient or Legal Representative
Name of Signee

First NameLast Name
Should be Empty:

Authorization for Release of Information

Release Information to and from the Following