Authorization to Release Information
Eclipse Therapy LLC
2091 Kerr Gulch Rd
Evergreen, CO 80439
720-339-1309
Email address *
Client Name *
Your answer
Date of Birth *
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Address *
Your answer
I understand this release is voluntary and applies to all programs and services operated under the auspices of Eclipse Therapy LLC. I understand that my personally identifiable information (PII) may be protected by the federal rules for privacy under the Family Educational Rights and Privacy Act (FERPA), the Health Insurance Portability and Accountability Act (HIPAA), and/or other applicable state or federal laws and regulations. I understand that my PII may be subject to re-disclosure by the recipient without specific written consent of the person to whom it pertains, or as otherwise permitted. I also understand that the recipient may not condition treatment, payment, enrollment or eligibility on whether I sign this form, except for certain eligibility or enrollment determinations. I understand that I may revoke this authorization at any time by notifying Eclipse Therapy LLC in writing but if I do, it will not have any effect on any actions taken before receipt of the revocation. *
Required
I hereby authorize Eclipse Therapy LLC to (check all that apply): *
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I hereby authorize Eclipse Therapy LLC to exchange / release / obtain information: *
Required
Organization or Individual receiving/communicating the information (Include name, address, and phone number. Include as many as you would like) *
Your answer
Description of information to be released/exchanged/obtained *
Required
Duration of release
From
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To
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State the purpose of the release *
Your answer
Client printed name *
Your answer
By typing your name and date below your are agreeing to electronically signing the above document *
Your answer
By typing your name in the above box, you are acknowledging your electronic signature of this document. Please check the box acknowledging your electronic signature. *
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A copy of your responses will be emailed to the address you provided.
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This form was created inside of Eclipse Therapy LLC.