AUTHORIZATION FOR THE DISCLOSURE OF PROTECTED HEALTH INFORMATION (PLEASE COMPLETE IN FULL)
____________________________________________________________________________________________________ Name of Client – Last, First, MI Birthdate Phone Number
____________________________________________________________________________________________________ Street Address City State Zip
Authorizes:To Use and Disclose Protected Health Information to:
Clinic For Christian Counseling, LLC Person/Organization: ______________________________________
505 South Dewey Street, Suite 208 Street Address: ___________________________________________ Eau Claire, WI 54701 City/State/Zip: ____________________________________________ (715 )832-1678 Phone: __________________________ Fax: ____________________
□ Check box to allow the above parties to exchange Protected Health Information
Type of Information to be Disclosed:Purpose of Information: ___ Psychiatric Evaluation ___ To facilitate counseling / therapy ___ Psychological Evaluation ___ To facilitate educational planning ___ Medical Information ___ To facilitate psychological evaluation ___ Alcohol / Drug Abuse ___ Payment of third party / insurance claim ___ School Records / Teacher Observations ___ Legal Investigation ___ Assessment and Psychotherapy Note ___ Coordinate care with physician ___ Information required to bill third party for services ___ Other ______________________________ ___ Other ______________________________
Re-disclosure Notice: I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans or health care clearinghouses, the health information disclosed as a result of this authorization may no longer be protected by the Federal privacy standards and my health information may be re-disclosed by such person(s) and/or organization(s) without obtaining my authorization.
Revocation of Authorization: I may revoke this authorization, in writing, at any time except for information already released as a result of this authorization. The written revocation must be given to the agency I authorized to release information.
I have a right to inspect and receive a copy of the records to be disclosed. I have a right to receive a copy of the authorization. I have a right to refuse to sign the authorization. Treatment, payment, enrollment or eligibility of benefits may not be conditioned on my signing this authorization.
If this authorization is for the purpose of filing an insurance claim, all benefits will be paid directly to the Clinic for Christian Counseling.
A fee may be charged for copying costs.
Expiration Date: ___ Authorization expires as of _______________________________. ___ Authorization expires after payment owed by third party payor is complete. ___ Authorization expires ______ month(s) from the date I sign this authorization. ___ Other: _________________________________________________________________________________
I have had the opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.
___________________________________________________ _____________________________ Client Signature Date Signed
___________________________________________________ _____________________________ Signature of Client’s Legal Representative Relationship to Client