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  • AUTHORIZATION TO RELEASE OR OBTAIN PROTECTED HEALTH INFORMATION

    This form is to be completed and signed by client or parent/guardian, if client is a minor. A signed form authorizes the release of, or obtainment of requested protected health information from your clinical record to an individual or facility.

  • I,         hereby authorize and give permission to Wavelength Psychotherapy, LLC (hereinafter "Provider) to     from third-party,  . I         understand that the medical record may contain information concerning me or my child's psychiatric, psychological, drug or alcohol abuse, sexual abuse treatment, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions, and that under law these records are classified as privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an expressed and informed consent. In addition, I         understand that those records will not be released to entities other than those designated by myself or my personal representative or otherwise provided in federal law.

  • INDIVIDUAL OR AGENCY INFORMATION

  •  -
  • I authorize "Provider" to release, discuss, disclose and/or request (from third-party indicated above) the following Protected Health Information (PHI) (Please check each applicable item):

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • This authorization will expire when the client is discharged from the current episode of care, treatment has been completed, the client rejects, declines and/or discontinues treatment and contact, is referred elsewhere, moves, or in the case of the client's death. This authorization may be canceled in writing at any time and that refusal to sign will not affect treatment.

  • Wavelength Psychotherapy, LLC

    hello@wavelengthpsychotherapy.com
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