Authorization for Release of Information

- Client name:*
  First Last
- Date of Birth*
  Month
  Day
  Year
I hereby authorize Cindy Lerner Counseling (hereinafter “Provider”) to disclose mental health treatment information and records obtained in the course of my psychotherapy treatment.
This information may be released to:*
For the purpose of:*
This Release of Information Authorization will remain in effect until terminated by me in writing.

My Rights

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

I understand that submission of this authorization is entirely voluntary, and I understand that treatment by any party may not be conditioned upon my signing of this authorization ( unless treatment is sought only to create health information for a third party or to take part in a research study ).

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

BY ENTERING MY NAME BELOW, I AM INDICATING MY INTENT TO ELECTRONICALLY SIGN THIS AGREEMENT AND I REPRESENT THAT BY SUBMITTING THIS DOCUMENT I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL TERMS HEREIN.
- Client (or Guardian) Signature*
  First Last
- Date*
  MM slash DD slash YYYY
Please Email me a copy of this Authorization*
- Yes, please send a copy to me.
- No, thank you.
Email
Comments
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