Authorization For Release Of Information
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1Authorization for Release of Information
Client Name__________________________________________________
Date of Birth____________________
This form, when completed and signed by you,
_____ authorizes me to release protected information from your clinical record to the person you designate and
_____ authorizes the person you designate to release information to Wendy Biondi, LMHC.
Name/Organization: _________________________________________________________________________
Address: _______________________________________
City/State/Zip:_____________________________
Telephone: _____________________________________
Fax: _____________________________________
This authorization for disclosure of protected information applies to the following types of information:
___Clinical Information
___Clinical Record
Other (Please specify) _______________________________
This authorization pertains or relates to information regarding myself and/or the following minor child/children
of whom I am the parent or legal guardian:
Name_____________________________________________________
Date of Birth____________________
Name______________________________________________________ Date of Birth____________________
I am requesting the release of this information for the following reasons, and subject to the following limitations:
___Continuity of Care
Other (Please specify)____________________________________________________
Limitations__________________________________________________________________________________
This authorization shall remain in effect until: (Fill in an expiration date or an event that relates to the purpose of the
disclosure.) ___Termination of Services
Other (Please specify) __________________________________________
If this authorization does not contain an expiration date or event, it expires 90 days from the date of my signature.
I understand I have the right to revoke this authorization, in writing, at any time, by sending such written notice to Wendy
Biondi Counseling. However, my revocation will not be effective to the extent that action has been taken in reliance on
my authorization or if this authorization was obtained as a condition of obtaining insurance and the insurer has a legal
right to contest a claim.
I understand that my therapist generally may not condition services upon my signing an authorization unless the services
are provided for the purpose of creating health information for a third party.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the
recipient of my information and no longer protected by the HIPAA Privacy Rule.
Signature of Client ______________________________________________
Date _______________________
Signature of Parent/Legal Guardian/DPOA___________________________
Date________________________
Note: A photocopy or facsimile of the above signatures shall be considered in lieu of the original.
If there is a fee for this service, please obtain prior approval from Biondi Professional Services.
140 S Arthur, Suite 690, Spokane, WA 99202-2260
Phone: (509) 590-6339 Fax: (509) 535-7073 E-Mail:
Website:
Biondi: ROI, 8/2012
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