Authorization Form Data

Authorization to Release Protected Health & Confidential Information

  • (this is used to send a copy of the document to the client)
  • I request and authorize the above-named person or class of persons to release the information specified below to the above-name person or class of persons.
  • Please list and specify:
  • Purpose:
  • I understand that the disclosure of health information is voluntary. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, or eligibility to obtain benefits, unless specific in this form. I certify that this request is made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this authorization at any time in writing by sending a letter to the facility Privacy Officer or their designee. I understand my revocation will not be effective to the extent that action has already been taken in reliance on it. I understand and I have authorized the disclosure of my mental health information to someone who is not legally required to keep it private, and understand that it may be re-disclosed and may no longer be protected by the Standards for Privacy of Individually Identifiable Health Information, set forth at 45 CFR Parts 160 and 164. I understand that I may inspect or obtain a copy of the information to be disclosed. I understand a fee will be charged for copies of my mental health record. I understand the facility will provide me a copy of the signed authorization form upon my request. If I have questions about disclosure of my mental health information, I can contact the facility Privacy Officer or their designee. I understand that treatment may not be denied if I refuse to sign this authorization, except: 1) If the authorization is the very reason for seeking the health care (e.g., a pre-employment physical), that health care may be denied; or 2) If the authorization is for disclosure to a research study, I may be denied the treatment that is part of the study. In addition, the following consequences might occur if I refuse to sign the authorization: 1) If the authorization is to demonstrate to a health plan that a service should be paid for, the health plan may refuse to pay for it, and 2) If the authorizing is sought by an insurer because I am seeking enrollment or eligibility, the insurer may deny me the coverage I am seeking. I understand that a health plan may not refuse payment or benefits if I refuse to authorize disclosure of certain psychotherapy notes. I understand and affirm, by my signature below, that the benefits and disadvantages of releasing the above information, if known, have been explained to me. A COPY OR TELEFAX OF THIS AUTHORIZATION WILL BE AS VALID AS THE ORIGINAL.
  • If you are an adult consenting to the release of information for a child/teen client, please indicate your relationship to the client: