Records Release Form - Haven of Hope Counseling

Release of Information Form

Authorization for Release of Records or Information

By filling out and signing this form you are giving Haven of Hope Counseling and the clinician(s) performing services permission to disclose/obtain information to/from another individual, agency, doctor, attorney, counselor, therapist, etc.

NOTICE TO RECIPIENT OF INFORMATION

Please note: This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. If the records are so protected, Federal Regulation (42 CFR Part 2) prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

This Release of Records or Information will be valid for one year unless revoked at an earlier time.

Client First Name

Client Last Name

Client Date of Birth

Client Social Security Number/Account Number

Are you the client or guardian?

Guardian First Name

Guardian Last Name

Guardian's Relationship to the Client

What is the reason for this release form?

Please enter the name of the individual, agency, doctor, attorney, counselor, therapist, etc. you wish Haven of Hope to Disclose/Obtain your imformation:

Please enter the address of where you would like your information sent/received:

Address Line 1

Address Line 2

City

State

Zip Code

If Other, please specify

How would you like your information released? (check all that apply)

Verbal

Photocopied

Written Letter

Other

If Other, please specify

By entering my name below I am authorizing my counselor/representative to testify in a deposition or any legal proceeding regarding my psychiatric/psychological/substance abuse treatment.

What is the purpose for this disclosure? (check all that apply)

To permit continuity of care

To permit case management (including reimbursement determinations) and processing of benefit claims

To enable my employer to make a determination on my employment status (including disability leave)

Other

If Other, please specify

I may revoke this consent at any time except to the extent that action has been taken in reliance upon it. If I do not revoke it, this consent will expire six months after I have terminated treatment with all providers affiliated with Haven of Hope Counseling. I understand that treatment or eligibility for sliding fee discount will not be a condition of signing this authorization. There are no consequences of refusing to sign this authorization. It should be understood that once the information is used or disclosed, it may be subject to redisclosure and may no longer be protected except as required by federal law.

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