Release of Information

Patient's Name

First NameLast Name

Patient’s Date of Birth

Date

Last 4 Digits of Patient's Social Security Number

Texas:

Ardent Grace Counseling and Teletherapy

25420 Kuykendahl Road

Suite B100, Office 114

Tomball, TX 77375

Name of Recipient

First NameLast Name

Provider Type or Relationship

Recipient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Recipient's Email

example@example.com

Recipient's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Recipient's Fax Number (If Applicable)

Please enter a valid phone number.Format: (000) 000-0000.

Purpose of Disclosure (One or More)

Description of "Other"

Information that I do NOT want to be disclosed (If Applicable):

Duration

Date

Conditions of Disclosure

Signature

Name of Signer

First NameLast Name

Relationship

NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.

Release of Information

Information about my treatment will be disclosed by the following:

Provider or Organization Authorized to Release Information.