Authorization to Release Information

Client Name:   Please enter client/child name
Client Date of Birth:

Month   January February March April May June July August September October November December     Day   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     Year   2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926
 

I authorize the exchange of healthcare information between Spencer Psychology and:
Note: Only one name per release. You can fill out multiple releases if needed. Exchange with:  
Address:
Phone/Fax:
Please enter name of Dr./family member/other person

Relationship to Client:

Healthcare Provider

Family Member/Partner

Other

Please select Relationship to Client  Please provide other info
Information to be Exchanged (Please check choice or write in details for “other”):

All Mental health information including substance use diagnosis, treatment or discussion

Other

Please select Information to be Exchanged  Please provide other info
Purpose of Release:

Coordination of Care with others involved in my treatment

Legal Proceeding

Other

Please select pupose of Release  Please provide other info  

This release does not authorize subsequent disclosure by its recipients. Authorization is valid for one year, unless otherwise instructed. I understand consent can be revoked by me at any time in writing, except to the extent that action has been taken in reliance on it by agents of Spencer Psychology. Notice of revocation can be emailed to admin@spencerpsychology.com, or faxing a letter to us at 812-961-3804, or mailing us a letter to 482 S. Landmark Ave, Bloomington IN 47403. If substance abuse treatment records are released, they will be accompanied by the following statement:
“This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 C.F.R. part 2.). The Federal rules prohibit you from making any further disclosure of this information unless the further disclosure is expressly permitted by the written consent of the person to whom it pertains or otherwise permitted by 42 C.F.R. part 2. A general authorization for release of medical records or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse present.” The covered entity may not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs the authorization when the prohibition on conditioning of authorizations under 45 CFR 164.508(4) applies.

 

I have read and fully understand the above statements as they apply to me. I voluntarily authorize this release.

Electronic Signature of Client/Parent/Guardian: Please enter your full name

Note: If client is 18 or over, client must sign this consent. A parent cannot sign on behalf of a child if the child is 18 or older.

Date: