Fillable Hipaa Authorization Form Alliance Counseling Education Center printable pdf download

Kim England, LCSW

1540 Keller Parkway, Suite 108-205

Keller, TX 76248

Phone: 817-374-9809

Fax: 940-539-9941

HIPAA AUTHORIZATION FORM

To:

______________________________________________________________________________________________

Client(s): _____________________________________________ DOB: __________________________

_____________________________________________ DOB: __________________________

I, the undersigned, hereby authorize and request Alliance Counseling and Education Center to disclose to and/or, acting on my behalf,

obtain from the above-named person or organization any and all records and information about the above client(s) in the following

areas:

□ All health information

□ Admission summaries

□ Police records

□ Dental care

□ Social histories

□ CPS records

□ School information

□ Treatment summaries

□ Probation/parole information

□ Day care information

□ Discharge summaries

□ Other:______________________

Verbal communications

Your initials are required to release the following information:

___ Mental health records

___ Psychotherapy notes

(excluding psychotherapy notes)

(cannot be combined with any other disclosure)

___ HIV/AIDS test results/treatment

___ Genetic information (including test results)

___ Drug, alcohol, or substance abuse records (including those covered under 42 CFR part 2)

The person signing this form will be responsible for any fees incurred from this request.

The purpose of this disclosure of information is to improve assessment and treatment planning, share

information relevant to treatment and when appropriate, coordinate treatment services. I understand that if I

am currently or become involved in a court related service that this information may be used in court. It may

be forwarded to the District Court and will be available to the attorneys of record and to parties to who

represent themselves. Information may be further released or disclosed by the court, attorneys, and/or the

parties involved. If other purpose, please specify: _______________________________________________________

The purpose of this disclosure of information is for completion of a court ordered evaluation. It may be forwarded to the District Court

and will be available to the attorneys of record and to parties to who represent themselves. I understand information used or disclosed

pursuant to this authorization may be subject to re-disclosure and no longer protected by HIPAA privacy regulations. Federal law

prohibits the person or organization to whom disclosure is made from making any further disclosure of

substance abuse treatment information unless further disclosure is expressly permitted by the written

authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. Other types of

information may be re-disclosed by the recipient of the information in the following circumstances: I consent to

re-disclosure of any information protected by 42 CFR part 2. I understand services, treatment, or payment cannot be conditioned on

signing this authorization.

I acknowledge that this authorization may be revoked via written notice at any time by sending written notification to Kim England,

LCSW at the above address. I understand that a revocation of the authorization is not effective to the extent that action has been taken

in reliance on the authorization. This release is effective until completion of the case unless otherwise revoked. A copy or fax of this

authorization is as valid as the original. Dates of service include the entire lifetimes(s) of the above named persons(s). I acknowledge I

have read this form, agree to the uses and disclosures of the information described, and was offered a copy of this authorization for my

records.

________________________________________________________________________________________________________

Self/Parent

Signature

Printed Name

Relationship to client(s)

Date

Hipaa Authorization Form Alliance Counseling Education Center

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