AUTHORIZATION TO RELEASE/OBTAIN INFORMATION

Client Name:__________________________________ DOB___________________________ SSN_____________________

1. I authorize the use or disclosure of the above named individual's health information as described below.

2. Roene Zohler MSW,LCSW is authorized to make the disclosure to AND/OR obtain information from:

Name: ______________________________________________________________________

Address/ph & fax number(s):_____________________________________________________________________________

3. The type of information to be used or disclosed is as follows (check the appropriate boxes and include other information where indicated)

 most recent history
 Psycho-social Assessment
 progress notes and/or treatment summary
 entire record  most recent discharge summary
 Consultation by phone and/or email  consultation reports from (please supply doctors' names): ________________________________________________  other (please describe): __________________________________________________________

4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about treatment for alcohol and drug abuse.

5. This information for which I'm authorizing disclosured or obtained will be used for the following purpose:
 my personal records
 sharing with other health care providers as needed for the continuity of my care.
 other (please describe): ________________________________________________________

6. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Roene Zohler MSW,LCSW. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

7. This authorization will expire (insert date or event): _____________________________________ If I fail to specify an expiration date or event, this authorization will expire sixty days from termination of mental health services.

8. I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

9. I understand authorizing the use or disclosure or obtainment of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment.

Signature of patient or legal representative________________________________________________

Date______________________________

Witness sign and date_______________________________________________________________

Home - About Roene - FAQ's - Sex Therapy -
Whole Person Psycotherapy - Couples Therapy - Life Coaching - Workshops & Seminars - Forms - Contact