Release of Information
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Email *
By signing your name in the space below you are agreeing with this statement: "By signing my name below and providing my date of birth I authorize Maria Droste Counseling Services to disclose information to and receive from the person(s) or company named herein."
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I authorize Maria Droste Counseling Services to disclose information to and receive information from: (In the space below, please write the name of the person or the company your are agreeing to have MDCS share information with AND any phone number, fax, or email to help us contact them.)
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Date of Birth *
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Revocation:
I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to Maria Droste Counseling Services at 1354 Hancock Street Suite 209 Quincy, MA 02169. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
Conditions:
I further understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned upon my providing or refusing to provide this authorization for the requested disclosure, except for either (a) the provision of research-related treatment, or (b) if the purpose of the treatment is solely to create PHI for disclosure to a third party. However, it has been explained to me that failure to sign this form may have the following consequences: I may not receive the best care if I do not allow my therapist to share important information about me with another person(s) that my therapist believes is important for my treatment.
Form of Disclosure:
Unless you have specifically requested in writing that the disclosure be made in certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format, or electronically.
I authorize the following information to be disclosed:
Please note:
Approximate dates of services at site from which information is requested (if needed):
The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. If other, please specify below.
Redisclosure: Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer protected by the federal standards for privacy of individually identifiable health information (45 CFR Parts 160 and 174) and state law. I understand that I may inspect or obtain a copy of the health information that will be used or disclosed pursuant to this authorization.
Expiration: Any Release of Information is valid for one year from the date you sign the form but the one year length may be shortened by you if you specify a date in the space below that may be less than one year. 

By electronically signing my name and date below, I understand that the information disclosed pursuant to this Authorization to the recipient may be subject to re-disclosure and may not longer be protected by the federal standards for privacy of individually identified health information (45 CFR parts 160 and 174) and state law. I understand that I may inspect or obtain a copy of the health information that will be used or disclosed pursuant to this authorization. I can request a copy of this signed authorization for my records. *
Date of Release Signature *
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If you are signing as a personal representative of an individual, please describe your authority to act for this individual (parent or legal guardian, power of attorney, healthcare surrogate, etc.)
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