Release of Information Form

    CONSENT FOR RELEASE/REQUEST OF CONFIDENTIAL INFORMATION

    Patient Name:

    DOB:

    I give permission to disclose my health and mental health care information between:

    Lynette Quast, Ph. DTrisha T Miller, Ph. D, Inc.Margaret Kelsey (Carver-Grupp), Ph. DJennifer Kozel, Ph. D, LCP, Inc.

    AND

    Name:

    Address:


    City, State, Zip:

    Phone:

    Fax:

    Email:

    INFORMATION TO BE DISCLOSED (includes verbal exchange)

    Intake SummariesBehavior ChecklistsPsychological Evaluation ResultsTreatment PlansTherapy NotesDiagnosisTreatment SummariesCommunications (To Include: Verbal, Written, Fax, Email, Electronic, etc.)
    Other  
    Check if ONLY allowing verbal exchange of information between parties above.

    Purpose of Disclosure

    DiagnosisLegal PurposesCoordinate ServicesOther

    Expiration Date

    This authorization will expire one year from the date of signature or 1 YEAR THIS WILL EXPIRE

    Revocation

    I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken based on this authorization.

    Authorization

    1. I authorize the above facility to disclose information as noted above.

    2. I understand it is possible that sensitive information such as alcohol and drug usage may be released.

    3. I understand that once the information is disclosed, it may be subject to re-disclosure by the recipient and may no longer be protected.

    4. I understand that this authorization is voluntary and I may refuse to sign.

    5. I also understand that unless allowed by law, my refusal to sign will not affect my ability to obtain treatment, receive payment, or eligibility for benefits.

    6. I understand that the exchange of information may include electronic transmissions.

    Specify Exceptions:

    Patient (if 18 years or older) or Legal Guardian (sign)


    Date:

    Print Name (include legal guardian name if signing for Patient/Person/Student

    **A PHOTOCOPAY OR FAX OF THIS AUTHORIZATIONSHALL HAVE THE SAME FORCE AND EFFECT AS THE ORIGINAL
    **PER HIPAA GUIDELINES RECORDS REQUESTS ARE TO BE FULFILLED WITHIN 30 DAYS.