FORM – Release of Information – Refreshing Waters Counseling

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

Released to name

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*

MM

DD

YYYY

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
Date of service
Date Format: MM slash DD slash YYYY
Date of service start
Date Format: MM slash DD slash YYYY
Date of service end
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*

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.

Name*

Date*

Relationship to Patient*

Signature (Client/Parent/Guardian)*