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Appointments
Contact Us
About Us
Blog
Client Forms
FAQ
HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF INFORMATION TO
Name
*
First Name
Last Name
Client Date of Birth
*
MM
DD
YYYY
Recipient Name or Organization for my Telehealth Hope Counseling to obtain and/or release information to:
*
Recipient Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Recipient Phone#
*
(###)
###
####
Recipient Email:
*
For the purpose of:
*
At my Request
For Coordination of Care
I request that my health information regarding my medical care and treatment be:
Released to
Obtained from
I authorize and request the disclosure of all protected medical information including the following:
*
Psychiatric Records
Discharge Summary
Treatment Plans
Psychological Records
Consultation Notes
Alcohol and Drug Tx
Inpatient Hospital Records
Lab Reports and Radiology Reports
Medication List(s)
I understand that:
*
I understand that signing this authorization is voluntary and that treatment or payment for treatment cannot be conditioned on the signing of this authorization
I understand the information disclosed under this authorization might be re-disclosed by the recipient.
I have the right to revoke this authorization at any time.
Client or Parent Signature
*
Date
*
MM
DD
YYYY
Thank you!