Consent for Release of Information
The purpose of this form is to authorize the parties indicated to disclose and exchange client information to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services with James McCracken, LCSW. The original of this form will be scanned into your treatment record, and a copy may be sent to other parties.
* Required
Client LAST Name
*
Your answer
Client FIRST Name
*
Your answer
Client Date of Birth
*
MM
/
DD
/
YYYY
Statement of Understanding
I (client) authorize James McCracken, LCSW, PLLC and the company or individual specified below to exchange specified information indicated below for the purpose of coordinating care. I understand that:
-I have the right to be told and to review the information being exchanged
-Information may be exchanged via phone, fax, email or in person
-This information will only be disclosed to parties specifically indicated, at which time those parties are responsible for maintaining the privacy of your information.
-I may refuse or revoke my consent at any time by writing a letter to James McCracken, LCSW, PLLC. I understand that the revocation will not apply to any information already used or disclosed under this authorization.
-This consent will be valid for one year following the conclusion of treatment with James McCracken, LCSW, unless otherwise indicated.
-I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from James McCracken, LCSW, PLLC.
-For further information regarding privacy practices, please review your "Consent for Treatment" and "Notice of Privacy Practices".
Name of company or individual you are permitting to disclose and exchange information with James McCracken, LCSW, PLLC:
*
Your answer
Company/Individual Contact Information (party James McCracken may exchange confidential information with)
*
Your answer
Your relationship to this person or company:
*
Your answer
This person or company's phone number and/or e-mail address:
*
Your answer
The following information may be shared by this person/company to James McCracken, LCSW, PLLC (check all that apply):
*
Attendance Records
Diagnostic Information
Intake summary and biopsychosocial history/assessments
Treatment Planning Information
Progress Notes and Information
Communications Records
Information about how your condition impacts your ability to work and Activities of Daily Living
Psychological and Psychiatric Assessment Information
Discharge Notes and Information
Recommendations
Complete copy of Medical/Health record (excluding Psychotherapy notes)
Other:
Required
The following information may be shared by James McCracken, LCSW, PLLC to this person/company (check all that apply):
*
Attendance Records
Diagnostic Information
Billing and payment records
Intake summary and biopsychosocial history/assessments
Treatment Planning Information
Progress Notes and Information
Communications Records
Information about how your condition impacts your ability to work and Activities of Daily Living
Discharge Notes and Information
Recommendations
Complete copy of Medical/Health record (excluding Psychotherapy notes)
Other:
Required
Statement of Consent
I consent to sharing the information specified and under the condition(s) specified within this release
Client (or Client Representative) Electronic Signature
*
Your answer
First AND Last name of legal guardian or legally authorized client representative
Your answer
Submit
Never submit passwords through Google Forms.
Forms
This form was created inside of James McCracken, LCSW, PLLC.
Report Abuse
Terms of Service
Privacy Policy