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317 N. Meldrum St., Fort Collins, CO, 80521 Email: [email protected] Phone: (970) 682.3947 Authorization for Release of Mental Health Information I authorize the use or disclosure of my individually identifiable health information as described below. I understand this authorization is voluntary. I understand that if the person/entity authorized to receive the information is not a health plan or health care provider, then the released information may no longer be protected by Federal privacy regulations. SECTION 1 - Identify the person whose information is to be released: Name: __________________________________________ Date of Birth: _______________________ SECTION 2 - Identify entity to disclose to and/or obtain from: Information is to be: Information is to Exchanged ____ OR Exchanged OR Released Received ____ Released be: (Please Check) Name: _______________________________________________________ Address: _____________________________________________________ City, State, Zip: ________________________________________________ ____ Received Phone: ______________________ Fax: ________________________ SECTION 3 – Content of Disclosure: (Please Check) Entire Record OR Evaluation, Assessment & Diagnosis Billing/Payment for Services Continuity of Care/Coordination of Services Scheduling Treatment Planning Substance Use/Abuse Issues Progress Notes Other:_________________________________ SECTION 4: I understand that I may revoke this authorization at any time (except to the extent that action has already been taken based on this authorization) by written notice to Soul Thrive Therapy LLC. If applicable, I further understand that I will agree to pay this agency the cost incurred in preparing the copy of the requested mental health records as outlined in the agency’s Mental Health Records Request Form. I understand that I can request a copy of this form after I sign it. Signature of Client/Guardian: ______________________________________ Date: ____________ Signature of Client/Guardian: ______________________________________ Date: ____________ A PHOTOCOPY OF THIS FORM IS AS VALID AS THE ORIGINAL NOTICE TO RECIPIENT OF INFORMATION This information has been disclosed to you from records the confidentiality of which may be protected by Federal and/or State Law. If the records are so protected, Federal Regulations (42 CFR Part 2) prohibit you from making any further disclosures of this information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains, or as otherwise permitted by 42 CFR 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 this information to criminally investigate or prosecute any drug or alcohol abuse patient.
