Release of Information

Release of Information

41400 Dequindre Rd, Suite 110, Sterling Heights, MI 48314 • P 586-580-2975 • F 586-580-2954 • info@silverliningspllc.com • silverliningspllc.com
Sharing your information, your choice

This form allows you to authorize Silver Linings Counseling to share information with an individual or organization of your choosing. You decide who may receive information, what may be shared, and which dates are included.

For communication with medical providers, please use our Coordination of Care form instead.
I authorize my therapist/SLC to:
Client Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
My SLC Therapist
DOB
Therapist Email
example@example.com
Approved Person
Relationship to You
Their Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Their Email
example@example.com
Their Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Office/Group Name
Their Address

Street Address

Street Address Line 2

CityState

Zip Code
Formatted address
Purpose of Disclosure
Information to be Disclosed
Which dates should we include?
Please specify the date range you'd like to include. If you'd like to include your entire time at SLC, please type "ALL"
If specific date range or length of time, please designate here
Example: last 6 months or mm/dd/yy - mm/dd/yy
Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Formatted date signed
Your relationship to the client:
Legal Acknowledgment

Re-Disclosure: I understand that this information may be protected by the Title 42 (Cod of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I understand that my Protected Health Information (PHI) that is used or disclosed under this authorization may be subject to re-disclosure by the recipient, and the privacy of my PHI may no longer be protected under these guidelines if they are not a health care provider covered by state or federal rules. The federak rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

Revocation of Authorization: I understand that this authorization is voluntary and may be revoked in writing at any time, except to the extent Silver Linings Counseling has already taken action upon it. I understand that if I revoke this authorization, I must do so in writing. Silver Linings Counseling will not condition treatment or payment based on this authorization or revocation of the authorization unless otherwise allowed by law.
Should be Empty: