Release of Information Consent

Release of Information Consent

Please fill out the information below completely. This form will be kept on file for one (1) year as a medical release. Submit another online form to update your release information.
CLIENT INFORMATION
State
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Client Phone Number
Client Email
example@example.com
SENDER INFORMATION
Party to Send Information*

Levan Counseling & Consulting dba Emerging JourneysName of party (Provider or Company) to send information
I authorize Sending [NAME OF SENDING PARTY]:*
Sending Party Email:
example@example.com
Sending Party Phone Number:
Sending Party Fax Number:
I authorize the above Party to:*

SendReceive
I authorize the above Party to SEND the following information:*

Medical history and evaluation(s)Mental health evaluationsDevelopmental and/or social historyEducational recordsProgress notes, diagnostic assessment, treatment plan or closing summaryForms sent for completion (for disability, etc.)Other
Do you need a specific date range?

YesNo
Start date of service requested*

MonthDayYear
Date
End date of service requested*

MonthDayYear
Date
RECEIVER INFORMATION
Party to Receive Information (Who should get files)*

Levan Counseling & Consulting dba Emerging JourneysSelfName of party to receive information
SEND TO:

Levan Counseling & Consulting dba Emerging Journeys
Attn: Admin
Email: admin@emergingjourneys.org
Fax: (612) 234-4788 Phone: (612) 254-0500
To Receiving: (Specific person to receive) :*
Receiving Party Email:
example@example.com
Receiving Party Phone Number:*
Receiving Party Fax:
Method to Send Information*

FaxEmailDropboxMail (Fees may apply)Verbal Only (Do not send records)Other (Fees may apply)
Link to Dropbox or other drop method (if available)
The above information will be used for the following purposes:*

Continuing CareInsurance companiesDisabilityForms CompletionLegalWorkers CompensationOther purpose
Document upload (Please upload necessary documents that authorize you to request records on behalf of client)

pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
I understand that this information may be protected by Title 42 (Code 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 further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules. I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.

Note: A client (18 years or older) must authorize the release of their own information unless patient is incapacitated or deceased. If signing for a minor patient, I hereby state that my parental rights have not been revoked by a court of law. Specific situation(s) may require minor’s authorization.
Signature*

Clear
Client/Parent/Guardian By checking this, you are eSigning this form.
Date*

MonthDayYear
Date
Name

First NameLast Name
Your relationship to client (legal documentation of right of access may be required):*

SelfParent/legal guardianPersonal representativeHealth care power of attorney/agentOther
Please verify that you are human*
Should be Empty:

Release of Information Consent

CLIENT INFORMATION

SENDER INFORMATION

RECEIVER INFORMATION