• AUTHORIZATION FOR RELEASE OF RECORDS

  • Authorization for the use and disclosure of Protected Health Information (PHI) is only for the person or agency on this form.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • I hereby authorize the above listed Provider/Agency/Organization to*

  • CP COALITION LLC (Venus Allen, LCSWA, LCASA, CMC) any and all medical, confidential, employment or other information requested regarding the above-named individual which it has in its possession. I also consent to this information being exchanged by means of electronic communication such as email or an electronic health records (EHR) portal.

  • The disclosure is to be used for:*

  • I understand that if the organization authorized to receive information is not a health plan or health care provider and if such information is re-disclosed by the recipient, the released information may no longer be protected by federal privacy regulations, but may be protected under federal and state law.

     

    • I understand that this authorization is voluntary.
    • I understand that the client’s health care and payment will not be affected if I do not sign this form.
    • I understand that I may receive a copy of this form after I sign it and that I may inspect and request a copy of the information I am authorizing for use or disclosure.
    • I understand that these records are to be kept confidential and the information is for use by that action has been taken in reliance upon it.
    • I understand and agree that this release may contain information pertaining to psychiatric, drug and/or alcohol diagnosis and treatment.
    • I understand that I may revoke my consent in writing at any time, except to the extent that an action has been taken in reliance upon it.
  • Date
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  • Date
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  • This release will expire one (1) year from the date hereof unless otherwise noted.

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  • Should be Empty: