Authorization To Disclose Protected Health Information Form printable pdf download

Authorization to Disclose Protected Health Information

I hereby authorize Deborah Tucker, MA (“Provider”) to disclose to (name and/or function of

the

person

entity

whom

disclosure

made)

__________________________________________________________________(“Recipient”)

the following protected health information:

____ Entire File

____ Psychotherapy Notes

____ Session Start/Stop Times

____ Diagnosis

____ Treatment Plan

____ Symptoms

____ Prognosis

____ Progress to Date

____ Clinical Test Results

____ Modalities & Frequencies of Treatment Furnished ____ Dates of Treatment

____ Other ______________________________________________________________

I understand that I have a right to receive a copy of this authorization, and that any

cancellation or modification of it must be in writing. I understand that I have the right to

revoke this authorization at any time unless Provider has taken action in reliance upon it. I also

understand that such revocation must be in writing and received by Provider to be effective.

I authorize the disclosure of the health information described above for the following purpose:

_____________________________________________________________________________

The specific uses and limitations on the uses of my health information by Recipient are as

follows: ______________________________________________________________________

_____________________________________________________________________________

I understand that Provider cannot condition treatment upon me signing this authorization.

I understand that the health information disclosed pursuant to this authorization may be

subject to re-disclosure by Recipient and that the Federal Privacy Rule may no longer protect

such information, although the re-disclosure of such information may be protected by

applicable California law.

Provider is authorized to disclose the protected health information specifically listed above

until: _____________________________(authorization expiration date).

By: _____________________________________Date: ____________________________

(Patient or Patient’s Representative*)

*If signed by other than Patient, please indicate the relationship between Patient and his/her

Representative: ________________________________________________________

Authorization To Disclose Protected Health Information Form