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.
Client LAST Name *
Client FIRST Name *
Client Date of Birth *
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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: *
Company/Individual Contact Information (party James McCracken may exchange confidential information with) *
Your relationship to this person or company: *
This person or company's phone number and/or e-mail address: *
The following information may be shared by this person/company to James McCracken, LCSW, PLLC (check all that apply): *
Required
The following information may be shared by James McCracken, LCSW, PLLC to this person/company (check all that apply): *
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 *
First AND Last name of legal guardian or legally authorized client representative
Submit
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