Authorization for the Release of Protected Health Information (PHI)

Authorization for the Release of Protected Health Information (PHI)
I hereby authorize the mutual exchange of information to and from the following person, provider, agency, or organization:
Name/Organization*
Phone Number

Area CodePhone Number
Fax

Area CodePhone Number
Other Contact Information
This release permits Bay Area Psychological Consultants and the above-named party to send and receive information as specified below.
Information to Be Shared (check all that apply):

All RecordsProgress NotesPsychiatric / Psychological EvaluationTreatment Summary and RecommendationsDiagnostic Test ResultsBilling and Appointment RecordsOther
Purpose of Disclosure (check all that apply):

Continuity of Care / Coordination of TreatmentLegal Proceedings / Attorney CommunicationTransitioning ProvidersInsurance / Disability ClaimPersonal UseOther
This authorization is valid until (check one):

One year from the date signedUntil revoked in writingOther
Your Rights and Acknowledgment
• I understand that I may revoke this authorization at any time by submitting a written request to my provider. Revocation does not affect disclosures already made in good faith.
• I understand that the information released may include sensitive material such as mental health or substance use treatment records.
• I understand that my provider may not condition treatment based on this authorization unless the services are for a third-party evaluation.
• I acknowledge that once information is disclosed, it may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA.
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Signature*

Clear
Name of Individual Signing Consent Form (if different from Client
Relationship to Client*
Should be Empty: