Release of Information

I hereby authorize
Released to name
to release my information to:
- Name*
- Email*
- Phone*
- Relationship*
Patient's First Name*
Patient's Last Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Date of Birth*
Date Format: MM slash DD slash YYYY
The purpose for which the following information is being requested*
I authorize the following information to be released from my records
- Date of service*
  Date Format: MM slash DD slash YYYY
- Date of service
  Date Format: MM slash DD slash YYYY
- Date of service
  Date Format: MM slash DD slash YYYY
- Date of service
  Date Format: MM slash DD slash YYYY
Please select the appropriate item(s)*
- Initial Assessment
- Session Notes
- Treatment Plan
- Emergency Contact Only
- Alcohol/Drug Assessment
- Alcohol/Drug Treatment Records
- Billing Information
- Other
Please Specify
I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon this authorization. If not previously revoked, this authorization will terminate on the following date, event, or condition
Date*
Date Format: MM slash DD slash YYYY
If no date, event, or condition is specified, this authorization will expire after 1 year.
- I further understand that I will agree to pay the facility the costs incurred by Refreshing Waters Counseling & Consulting in preparing the copy of the requested mental/behavioral health records as allowed by State and Federal guidelines.
- I understand that no treatment, payment, enrollment, or eligibility for benefits may be conditioned on whether I sign this authorization.
- The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
- The information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected by federal law, except for drug and alcohol treatment information.
- I understand that I am entitled to a copy of this authorization.
- I understand that my alcohol and/or drug treatment records are protected under Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. Parts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows.
Printed Name*
Date*
Date Format: MM slash DD slash YYYY
Relationship to Patient*
Signature (Client/Parent/Guardian)*