Patient Authorization to Release Information

This form, when completed and signed by you, authorizes this counseling provider to release protected information from your clinical record and/or psychotherapy notes to the person or agency you designate.

Patient Authorization

First Name

Last Name

I authorize John Marshall Jenkins PhD, LLC, to release (check all that apply):

all clinical records

all psychotherapy notes

and/or the following specific records or notes (be as detailed as possible):

This information should only be released to:

Name/Agency

Address

City

State

Zip Code

Phone

I am requesting my provider to release this information for the following reasons (“at the request of the individual” is all that is required if you are my patient and you do not desire to state a specific purpose):

This authorization shall remain in effect until (usually 1 year):

Agreed

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the provider authorized above to release information. However, my revocation will not be effective to the extent that the provider 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.

Agreed

I understand that my provider generally may not condition services upon my signing an authorization unless the services are provided to me for the purpose of creating health information for a third party.

Agreed

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.

Agreed

I understand this form must be completed in full in order for the request to be processed.

Signature of Patient

Clear

Date of Birth

If the authorization is signed by a personal representative of the patient, a description of such representative's authority to act for the patient must be provided here:

If you are human, leave this field blank.