Assessment and Therapy Associates of Grand Forks, PLLC
3535 S. 31st St., Suite 201, Grand Forks, ND 58201
701-780-6821 (phone) | 701-780-1973 (fax)
www.grandforkstherapy.com

This release of information will be submited to ATAGF via HIPAA-secure and encrypted means. To protect your information and verify your identity, we require you to upload a picture of a photo ID card (driver's license, student ID, etc.) that belongs to you (the patient) or a parent/legal guardian (for patients under 18yo).

If you are not comfortable filling out this form online using this HIPAA-secure, encrypted format, or are unable/unsure how to upload picture of your photo ID, please contact our office at (701) 780-6821 to receive this form in a different format (paper version or fillable PDF). 

Please note that this paperwork is not monitored in real-time and submissions are only reviewed from 8am to 5pm, Monday through Fridays (excluding holidays or dates ATAGF is closed).

Assessment and Therapy Associates of Grand Forks, PLLC
3535 S. 31st St., Suite 201, Grand Forks, ND 58201
701-780-6821 (phone) | 701-780-1973 (fax)
www.grandforkstherapy.com

This form, when completed and signed by you, authorizes outside agencies or individuals to release Protected Health Information (PHI) including mental health, educational, or substance abuse treatment records, from the above named patient’s medical, educational, and/or clinical records to Assessment and Therapy Associates of Grand Forks, PLLC by mail, facsimile, or personal communication. Your signature indicates that you understand that these records may contain information regarding drug, alcohol, psychological, or psychiatric conditions and communicable diseases and that they are protected by Federal Law (42CFR Part 2) and cannot be disclosed without this written consent unless otherwise provided in the federal regulations. Your signature also authorizes any receiving individual or entity to honor copies of this signed form as having the same legal authority and force as the original.

I authorize the following individuals, agencies, or their representative to release and exchange information with Assessment and Therapy Associates of Grand Forks, PLLC and/or its administrative and clinical staff:

I understand that this authorization will remain in effect upon fulfillment of the above stated purpose or twelve (12) months from the date of my signature (whichever occurs first). This consent will automatically expire without my express revocation. I understand that I may revoke this consent at any time, except to the extent action has already been taken in reliance on it, by notifying the provider of the information in writing and that my cancellation will take effect when the provider receives my written notice.

I understand that treatment, payment, enrollment, or eligibility of benefits may not be conditioned on obtaining this authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of this information, and no longer protected by the HIPAA Privacy Rule or by Federal or State law or rules. Assessment and Therapy Associates of Grand Forks, PLLC, its staff, interns, and students are hereby released from any legal responsibility or liability for disclosure of the above information covered under this Authorization.