AUTHORIZATION FOR COMMUNICATION
PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)
Email address *
Client Name *
Your answer
Client's Birthdate *
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Name of person or entity to contact. *
Your answer
Contact information of person or entity to contact (phone, address, and/or email). *
Your answer
I authorize Kids On Up Psychotherapy to COORDINATE CARE with the person or entity listed above my by releasing and/or obtain the following PHI: *
In addition to COORDINATION OF CARE, I am requesting this release of information for the following reasons: *
Required
This authorization in effect for up to one year 1 year or until the date listed below. *
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I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Kids On Up Psychotherapy. However, I understand that any revocation will not be effective to the extent that Kids On Up Psychotherapy has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that Kids On Up Psychotherapy generally may not condition psychological or psychiatric services upon -my signing an authorization unless the services are provided to me for the purpose of creating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of my information and no longer protected by the HIPAA Privacy Rule *
Required
I acknowledge that by TYPING MY NAME, this is considered a legal and binding document. *
Your answer
Today's Date *
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