AUTHORIZATION FOR COMMUNICATION

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

Email *

Client Name *

Client's Birthdate *

YYYY

Name of person or entity to contact. *

Contact information of person or entity to contact (phone, address, and/or email). *

I authorize Kids On Up Psychotherapy to COORDINATE CARE with the person or entity listed above by releasing and/or obtain the following PHI: *

My entire record

Summary of assessment/treatment

Testing report

HIV/Aids

Information needed to file insurance

Substance abuse

Other:

In addition to COORDINATION OF CARE, I am requesting this release of information for the following reasons: *

At my request

Filing insurance claims

Transfer of care

Other:

Required

This authorization in effect for up to 1 year or until the date listed below.

YYYY

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 *

I acknowledge.

Required

I acknowledge that by TYPING MY NAME, this is considered a legal and binding document. *

Today's Date *

YYYY

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of KIDS ON UP PSYCHOTHERAPY INC.. Report Abuse

Forms