PCP Release of Information| Renewal Christian Counseling Center

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First Name*

First

Last Name*

Last

Which best describes you?*

Office Location*

Date of Birth*

Month

Day

Year

Email*

Authorization

I authorize Renewal Christian Counseling Center to disclose my Private Health Information (PHI) to the following person(s) / Organization(s):

Full Name*

First

Phone*

Address*

Street Address City State ZIP Code

Disclosure Information

What is the purpose of the information being released?*

I give permission to release the following information:*

*Check all that apply

Entire Mental Health Record

Treatment Plan & Recommendations

Diagnosis / Assessments

Progress Notes

Specifics of Information Requested:*

I want the information above to be released in the following form:*

*Check all that apply

Written

Verbal

Electronically

Other

CONSENT AND SIGNATURE

I understand that if the person(s) or organization(s) that receives the information is not a health care provider or health care plan covered by federal privacy regulations, the information described above my be redisclosed and no longer protected by these regulations.*

I understand this authorization will expire (not to exceed one year or one year from termination of treatment), I further understand that I may revoke this authorization at any time by notifying Renewal Christian Counseling Center in writing, but I understand that previously disclosed information would not be subject to my revocation request.*

Client or Parent/Guardian Signature*

Date*

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

Primary Care Physician Release of InfoRmation

Authorization

Disclosure Information

CONSENT AND SIGNATURE