Consent for Release of Information
If you would like your therapist to be able to speak to others about your treatment, please complete this form. This is often used for communication with other providers for you and your family.
Email address *
Client's Name *
Client's Date of Birth *
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Client's Phone Numer *
Federal Regulation, 42 CFR Part 2, requires a description of how much and what kind of information is to be disclosed.
The following information is to be released for the purpose of continuity of care:
The extent of information to be disclosed is my diagnosis, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program, prognosis, and recommendations.
I authorize medical/mental health information to be exchanged between:
A New Hope Therapy Center
715 E Idaho Ste 2B Las Cruces, NM 88001
Phone: 575-556-9585 Fax 575-556-9456 and the following organization, provider or other person listed below.
Organization, Provider, Other Person's Name *
Organization, Provider, Other Person's Address *
Organization, Provider, Other Person's Number *
Organization, Provider, Other Person's Fax Number
Information to be Released: *
Please specify what records to release below.
By initialing the spaces below, I specifically authorize the voluntary release of the following medical records, if such records exist. I understand they are protected by Federal & State Law. I also understand that I may revoke this authorization at any time except to the extent that information has already been released based upon this authorization. *
Yes
No
Mental Health Treatment Information
HIV/AIDS Related Records
Drug/Alcohol Diagnosis, Treatment Information
My consent may be revoked at any time. The only exception is when the action has already occurred as instructed in the consent. Unless I revoke this authorization prior to such time, this authorization to release my information shall expire at one year from the date of my signature or the termination of services, whichever occurs first.
Typing your full name indicates consent and agreement: *
Today's Date: *
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