• Authorization to Release Protected Health Information (PHI)

    Authorization to Release Protected Health Information (PHI)

  • Your PROTECTED HEALTH INFORMATION (PHI) includes any individually identifiable health information (e.g., medical records) that is transmitted or maintained in any form (e.g., orally, electronically, by mail).

  • Patient Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • What are you authorizing?*
  • Is the other party a specific person or an agency (e.g. a clinical practice)?*
  • This party is a:*

  • Between which dates of service are you authorizing the disclosure of your PHI?

    The following fields must capture the intended dates of service for this form to comply with HIPAA regulations. You may estimate if you are unsure of the month/day. 

    Enter the date you first began treatment and the last date of treatment with the provider or agency.

  • Treatment start date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Treatment end date*
     / /
    2 digit month, 2 digit day, 4 digit year
    • If treatment is ongoing, put one year from today in "Treatment end date". 
    • If you are authorizing an exchange of all information, be sure to capture the date you began seeing whichever provider/agency you have been seeing the longest.
    • You may estimate if you are unsure, but the dates must capture the date(s) of service you are authorizing.
  • How are you authorizing your PHI to be disclosed to the other party?*
  •  -

  • EMAIL: By indicating that you authorize the transmission of your PHI by email, entering an email address into email field, and signing this document electronically, you attest that you understand that email is not considered to be a secure means of communication and accept the risks of transmitting your PHI by email. Your PHI may be vulnerable while in transit and after it is received by your email server. The kinds of parties that may intercept these messages include, but are not limited to:

    • People (e.g., in your home or workplace) who can access your device
    • Your employer, if you use your work email to communicate with us
    • Third parties who monitor internet traffic
    • People who may “hack” email or devices

  •  -

  • PICK-UP: If Etheridge Psychology is to release your printed PHI by pick-up, you must make an appointment with us to pick it up. Only the person listed may pick up your PHI and must present valid ID. The patient may also pick up their own PHI with valid ID unless prohibited by law (e.g., they are a minor). If the other person/agency is to release your PHI, you must contact them directly for the address and instructions to pick up the records.

  • What specific PHI are you authorizing to be disclosed to the other party?*

  • Why are you authorizing the disclosure of the specified PHI?*

  • IMPORTANT: Please carefully check that all fields are completed correctly to avoid being required to complete a new form. Dates of service are especially important to double check.

  • By electronically signing this document, I attest that I understand the following:

    • The information disclosed may include sensitive information relating to mental health and may contain information regarding sexual abuse/assault, drug/alcohol use, HIV/AIDS and other communicable diseases, and genetic testing that has been disclosed to Etheridge Psychology or the other person or agency I indicated on this authorization.
    • I have the right to inspect or copy the PHI that is used or disclosed and that I must make a request to inspect or copy the information from the provider who is disclosing the information, not the provider receiving the information.
    • I may get a copy of this authorization by pressing the "Print or Save Completed Form" button on this form or by calling Etheridge Psychology at (919) 600-4906.
    • I may cancel this authorization at any time in writing to Etheridge Psychology. Revocation of this authorization will not affect any disclosures of PHI made prior to revocation of this authorization.
    • Once my PHI is disclosed, it may be re-disclosed by the recipient of the information and no longer protected.
    • I understand I am not required to sign this authorization, my treatment is not conditioned upon the signing of this document, and I may have any questions regarding this document answered prior to my signature or refusal.
    • This authorization will be in effect and valid for one year from the date of signature unless revoked in writing.

  • By signing below, I acknowledge that I have read and agree to this document and consent to the use of my electronic signature. If signing on behalf of a patient, I affirm that I have legal authority to do so.

  • What is your relationship to the patient whose PHI is being authorized?*

  • Minor children: A parent or legally appointed guardian of a minor child must sign this form. A stepparent is not a legally appointed guardian unless a court has appointed them as a legal guardian with authority to consent to health care services for the minor patient.

    Dependent adults: A legally appointed guardian with authority to consent to health care services for the patient must sign for the patient.

    Other Legal Representative: Indicate your legal authority to sign this authorization for the patient listed on this form.

    Important Note: A power of attorney (POA) form is insufficient for establishing yourself or someone else as an authorized representative as defined by HIPAA. For a POA to be in effect, a physician or licensed psychologist must make the determination that the patient lacks understanding or capacity to make or communicate health care decisions. Please see North Carolina statutes G.S. § 32A and G.S. § 32C. 

  • If you would like a copy of your completed form, click "Print or save completed form" after completing the form but before clicking the "submit" button. You may also ask us for a copy of your completed form.

    Don't forget to click the submit button!

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