FORM – Release of Information – Refreshing Waters Counseling

I hereby authorize Refreshing Waters Counseling to release my information to:

Released to name

Purpose

Field Group Open

Name*

Email*

Phone*

Relationship*

Field Group Close

Patient's First Name*

Patient's Last Name*

Patient Address

Patient City

Patient Zip

Patient State

Patient Phone*

Date of Birth*

MM

DD

YYYY

Field Group Open

I authorize the following information to be released from my records*

All dates of service
Single date of service
A range of dates of service

All Dates

Through

Date of service

Date of service start

Date of service end

Field Group Close

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

If no date, event, or condition is specified, this authorization will expire after 1 year from last date o