Authorization for use/Disclosure of Protected Health Information Lakewood This form is required for the release of information and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy standards and other applicable Federal and State privacy and confidentiality statutes and regulations. I voluntarily consent the following provider to disclose my protected health information (PHI) during the term of this authorization to the recipient(s) that I have identified below. ProviderName:*Address:*RecipientName:*Address:*Information to be Disclosed I authorize the release of the following PHI: (e.g. Evaluation, FBA, IEP, Treatment Plan) TermI understand that this authorization will remain in effect: (Please check applicable option)* From the date of this authorization until (please insert date below) Until the provider fulfills this request Until the following event occurs (please insert event below) Authorization will remain in effect until the following date* MM slash DD slash YYYY Authorization will remain in effect until the following event occurs*Coordination of ServicesI authorize Connect Plus Therapy to have written agreements to coordinate services with other service providers, including, but not limited to the following (Please check applicable option):* Select All Psychiatric inpatient facilities Related service professionals (SLP, OT, PT, SI, BSC, TSS, etc) Member’s of the client’s educational team Primary Care Physician Partial hospitalization programs Psychiatric outpatient clinics Crisis intervention programs Mental health and intellectual or developmental disability case management programs. Refusal to Sign/Right to Revoke I understand that signing this form is voluntary and that refusal to sign will not affect the quality of treatment but may cause an interruption in collaboration with other providers and/or insurance authorizations. I understand that I can revoke this authorization, in writing, at any time. The revocation will be effective immediately upon the receipt of the written request.Agreed to and Accepted:Parent/Guardian's Name (1)* First Last Parent/Guardian's Date of Signature (1)* MM slash DD slash YYYY Parent/Guardian's Signature (1)*Parent/Guardian's Name (2) First Last Parent/Guardian's Date of Signature (2) MM slash DD slash YYYY Parent/Guardian's Signature (2)Client's Name* First Last Client's DOB* MM slash DD slash YYYY
