This form, when completed and signed by you, authorizes Psychological Counseling Services, Ltd. (PCS) to release, request, or exchange protected health information from your clinical record to the person or agency you designate.
*Please initial where applicable
Initial if applicable
PHI only – Personal health information, (PHI) also referred to as protected health information, generally refers to demographic information, medical history, test and lab results, insurance information and other data that is collected by health care professional to identify an individual and determine appropriate care.
*(One Person OR Organization Per Form)
i.e. Individual/couples therapist, spouse, attorney, etc.
If you would like this authorization to expire SOONER than ONE (1) year from today, please specify here:
THIS DATE MUST BE A MINIMUM OF 60 DAYS FROM THE DATE COMPLETED
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to PCS. I also understand that my revocation will not be effective to the extent that PCS has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.
I understand that these records may have information protected by federal confidentiality rules (42 CFR part 2) regarding substance use disorders either directly or by reference. I authorize release of this substance use disorder information to this party. The recipient may not disclose this information to another party or entity without my express written permission.
This signature confirms all information provided in Sections A, B, C, & D of this Authorization to Release Information.