Release of Information

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INFORMATION, AUTHORIZATION, & CONSENT TO TELEMENTAL HEALTH

Stephanie L. Ezust, Ph.D., P.C.
www.DoctorEzust.com
Stephanie@DoctorEzust.com

Gus Kaufman, Ph.D.
www.OakhurstPsychotherapy.com
gkaufmanjr@aol.com

1123 Clairmont Road
Decatur, GA. 30030

Fax: (404) 371-9172
Phone: (404) 371-9171 (Dr. Ezust ext 1 Dr. Kaufman ext 2)

This form, when completed and signed by you, authorizes us to exchange protected information from your clinical record with the person you designate.

Email *

Client Name

Client Phone

I authorize my group psychologists, Stephanie L. Ezust, Ph.D and Gus Kaufman, Jr, Ph.D., to release: (Please provide a description of the information you’d like us to disclose. Your description should be as specific and detailed as possible although it’s fine to check, “All relevant information” if you don’t wish to limit the information released to the individual below.)

All relevant information

Other:

Therapist Information Authorization

I authorize my individual therapist to provide information to Stephanie L. Ezust, Ph.D. and Gus Kaufman, Jr,. Ph.D. about my treatment.

This information should only be released to the following individual and/or their staff:

Name

Address

Phone Number

Right to revoke

You have the right to revoke this authorization, in writing, at any time by sending written notification to our office address or by speaking to us about it during a session. However, your revocation will not be effective to the extent that we have 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.

Check box to agree *

I understand that my group psychologists, Stephanie L. Ezust, Ph.D. and Gus Kaufman, Jr., Ph.D., generally may not condition psychological services upon my signing an authorization unless the psychological 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 your information and no longer protected by the HIPAA Privacy Rule.

Required

Client E-Signature

Please type your full name below as your e-siganture to acknowledge your statement of agreement above

Date

YYYY

Submit

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