Authorizaton Form For Mutual Release Of Client Information Page 2

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PATIENT RIGHTS AND HIPAA AUTHORIZATIONS
The following specifies your rights about this authorization under the Health Insurance Portability and
Accountability Act of 1996, as amended from time to time (“HIPAA”).
1. Tell your mental health professional if you don’t understand this authorization, and they will explain it to
you.
2. You have the right to revoke or cancel this authorization at any time, except: (a) to the extent information
has already been shared based on this authorization; or (b) this authorization was obtained as a condition
of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in
writing to your mental health professional and your insurance company, if applicable.
3. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain
treatment, make payment, or affect your eligibility for benefits. If you refuse to sign this authorization, and
you are in a research-related treatment program, or have authorized your provider to disclose information
about you to a third party, your provider has the right to decide not to treat you or accept you as a client in
their practice.
4. Once the information about you leaves this office according to the terms of this authorization, this office
has no control over how it will be used by the recipient. You need to be aware that at that point your
information may no longer be protected by HIPAA.
5. If this office initiated this authorization, you must receive a copy of the signed authorization.
6. Special Instructions for completing this authorization for the use and disclosure of Psychotherapy
Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes.”
All Psychotherapy Notes recorded on any medium (i.e., paper, electronic) by a mental health professional
(such as a psychologist or psychiatrist) must be kept by the author and filed separate from the rest of the
client’s medical records to maintain a higher standard of protection. “Psychotherapy Notes” are defined
under HIPAA as notes recorded by a health care provider who is a mental health professional
documenting or analyzing the contents of conversation during a private counseling session or a group,
joint, or family counseling session and that are separate from the rest of the individual’s medical records.
Excluded from the “Psychotherapy Notes” definition are the following: (a) medication prescription and
monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment
furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status, the
treatment plan, symptoms, prognosis, and progress to date.
In order for a medical provider to release “Psychotherapy Notes” to a third party, the client who is the subject of
the Psychotherapy Notes must sign this authorization to specifically allow for the release of Psychotherapy Notes.
Such authorization must be separate from an authorization to release other medical records.
Client Name
_________________________________________
Client Signature
_________________________________________
Date
_____________________________

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