Release of Information "*" indicates required fields 1INFORMATION TO RELEASE2REVIEW & SIGN SECTION 1 Patient Information Please complete the following fields.Client's First Name* First Client's Last Name* Last Date of Birth* MM DD YYYY Office Location*Choose OneBay CityGrosse PointeMidlandMount ClemensPort HuronSaginawEmail* Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SECTION 2 Type of Health Information to be Released or Disclosed Please check all that applyRequest to Release the Following Information:* Entire Mental Health Record Diagnosis / Assessments Psychotherapy Session Notes Presence/Participation in Treatment Treatment Plan & Recommendations Billing Records Other Please Specify* SECTION 3 Purpose of Request / Disclosure Please check all that apply.Purpose* AD(H)D Testing Continuation of Care Insurance Legal Other Please Specify* SECTION 4 What action should be taken? Please select an option.Release Action* Release a copy of my health information to me. Release my health information to someone else. I have listed where I would like my health information to be sent in Section 5 below. SECTION 5 Where would you like your information sent? Please check all that apply.Release Method* I would like to have it emailed to me at the email address listed in Section 1. Please mail it to me at the address listed in Section 1. Please mail it to the address below. Please fax it to the number below. I authorize the verbal disclosure of information specified in Section 2 to the person or organization listed below. First Name* First Last Name* Last Phone*Fax*Email Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code You're almost done. You must sign the form or it WILL NOT be submitted. ImportantHealth Information sent in an unencrypted email is not secure. The Health Information may be intercepted and seen by others. There are other risks with an unencrypted email including misaddressed or misdirected messages, email accounts that are shared, messages forwarded to others, and messages that are stored on servers that have no security. By choosing to receive your Health Information by unencrypted email, you are acknowledging and accepting these risks. Your name, home address, insurance information, medical information, and other personal information may appear on the records we are sending to you. This Authorization is valid for one year from the date that I signed unless another date is listed below. This Authorization is voluntary. My treatment will not be impacted even if I do not sign this Authorization. My Health Information may include information about behavioral or mental health services, treatment for alcohol and drug abuse. I may revoke or withdraw this Authorization, except to the extent that action has been taken prior to the receipt of the revocation or withdrawal, by mailing or faxing my written request along with a copy of the original Authorization to the department where my Authorization was made or given. The information to be released maybe from my electronic health record (EHR). I understand that the data from the EHR are current as of the date printed. I further understand that in reducing the data to paper, information from the electronic database is being reformatted onto paper and the page numbers may reflect the printed document, not actual pages in the EHR. Once my Health Information is disclosed as requested, it may no longer be protected by federal or state privacy laws and could be re-disclosed by the person(s) receiving it. If I am not making this request in person, I may be asked to provide a copy of my current driver’s license or state identification. This release is being made at my request. Voluntary Choice to Release Health Information* I understand and agree to the above Health Information Risks and voluntarily choose to proceed with the release of the information I have selected in this document.Consent to Release Information* I understand this authorization will expire one year from the date signed unless another date is provided here (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.Relationship to Client*SelfParent / Legal GuardianSigning Parent / Legal Guardian's Name* First Signature*Date* MM slash DD slash YYYY Authorization is valid for one year from the date signed unless another date is provided here.CommentsThis field is for validation purposes and should be left unchanged. Copyright 2020 © Renewal Christian Counseling Center
