Continuing Hope Counseling LLC [condensed]

Continuing Hope Counseling LLC
534 10th Ave • P.O. Box 73536 • Fairbanks, AK 99707 • Phone (907) 451-8208 • Fax (907) 451-8207
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
Client Full Legal Name:   First Name   Last Name Client Date of Birth:   Date
Name of Parent/Guardian:   First Name   Last Name
Client Address:   Street Address   Address Line 2   City   State   Zip
I hereby authorize Continuing Hope Counseling, LLC to (Initial Applicable Boxes):
Obtain Confidential Information From:Disclose Confidential Information To:Exchange Confidential Information With:
Name: First Name Last Name Phone #: Phone Number
Address: Street Address Address Line 2 City Fax #: Phone Number
1. The purpose for which this information may be disclosed:
TreatmentInsuranceCare CoordinationOther
2. What information may be disclosed:
Presence in TreatmentPsychological Reports/TestsAppointment InformationProgress in TreatmentDiagnostic AssessmentDischarge SummaryDiagnosis/PrognosisAlcohol & Drug Abuse Records (Protected by Federal Confidentiality Rules 42 CFR Part 2 whichprohibit any further disclosure unless further disclosure is expressly permitted or written authorization bythe person to whom it pertains or as otherwise permitted by 42 CFR Part 2).Other
3. Request Information Dates from: Date to: Date

4. This authorization expires twelve (12) months from the date of my signature below
5. I understand that:
- The Federal Privacy Rule (HIPAA) does not protect the privacy of information if re-disclosed and therefore request that all information obtained be held strictly confidential and not be further released by the recipient. I intend this document to be a valid authorization conforming to all requirements of the Privacy Rule and state laws
- I may revoke this consent at any time by completing a written Revocation of Release of Information Form. Revoking this authorization does not apply to information that already has been released under this authorization.
- I need not consent to the release of information in order to obtain services. I choose to do so willingly for the purpose(s) specified above.
- My signature below asserts and confirms my legal authority to sign on behalf of the minor.
Signature of Client or Authorized RepresentativeSignature Date:   Date
Printed Name:   First Name   Last Name   Relationship:
Witness:   First Name   Last Name

I, [Name]   First Name   Last Name   , revoke my consent for exchange of information between the aforementioned entities.
Signature of Client or Authorized Representative:   Signature   Date:   Date
Should be Empty:

Continuing Hope Counseling LLC

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION