Release of Information Form

Complete via our secure web-form below or download, completed and returned to us.

RELEASE OF INFORMATION

Step 1 of 6

Patient Authorization for Disclosure

of PHI (Personal Health Information)

RELEASE OF INFORMATION

Client Name

Address

Street Address Address Line 2 City State ZIP Code

Birthdate

(your name)

authorize Anna Maith, LGPC to:

send

recieve

receive the following

From: (Name)

Address

Street Address Address Line 2 City State ZIP Code

Name

Address

Street Address Address Line 2 City State ZIP Code

The above information will be used for the following purposes:

Planning Appropriate Treatment or Program

Continuing Appropriate Treatment or Program

Determining Eligibility for Benefits or Program

Case Review

Updating Files

Other

if Other:

Consent

I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individuallv Identifiable Health Information, Parts 160 & 164) & Tile 45 (Federal Rules of Confidentiality of Alcohol & Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand the information disclosed to the recipient may not be protected under these guidelines if the recipient is not a health care provider covered by state or federal rules. I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, & after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, & who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.

Your relationship to the client:

Self

Parent!/ Legal Guardian

Personal Representative

Other

Acknowledgement

If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.

Client Signature:

Date

Parent/Guardian/Persona Representative (if applicable) Signature:

Date

Witness (if client is unable to sign) Signature:

Date

Proceed to Welcome Information Form

yes

Third Choice

Questions / Concerns

Use the form to contact us with your questions and concerns. We will have someone contact you as soon as possible.

You can also use the information below to contact us.

Thank You

Email

Info@abundanceofhopellc.com

Phone

443.242.4098