Spencer Psychology

Authorization to Release Information

Client Name:  

I authorize the exchange of healthcare information between Spencer Psychology and:
Releasing To:  
Address:
Phone/Fax:

Relationship to Client:




I  authorize and consent for agents of Spencer Psychology to release and/or exchange with the organization/person designated above the following information concerning my behavioral and mental health plan and/or alcohol/drug treatment. A faxed copy of this release is to be considered the same as the original.

Information to be Released (Please check choice or write in details for “other”):


Prohibition of Redisclosure: This release does not authorize subsequent disclosure by its recipients. If the record contains drug or alcohol information, it may be protected by the Confidentiality of Alcohol and Drug Abuse Patient Records (42CFR Part 2). The Federal rules prohibit any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Purpose of Release:


 

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

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.


Your Signature:  

Date: