Hidden Lakes Counseling • 1664 Keller Parkway, Suite 101 • Keller, TX 76248 • 817.854.3201
Authorization for Release of Confidential Information (open printer friendly PDF version)
I, ________________________________, have received and reviewed the Hidden Lakes Counseling Notice of Privacy Practices. I understand that only employees of Hidden Lakes Counseling may ask me to sign this authorization.
I understand that by signing this General Authorization, I am authorizing Hidden Lakes Counseling to disclose my health information to the persons and entities listed below and that any health information or other confidential information in the possession of the persons and entities listed below may be disclosed to Hidden Lakes Counseling. My health information includes, without limitation, any records, reports, test results, opinions, assessments and any other information relating to medical, emotional, educational or psychological condition. Disclosure may also be made to describe my condition and progress and to discuss treatment.
I understand that I may revoke this authorization at any time by sending a written notice of revocation to the counseling supervisor at the Hidden Lakes Counseling office where I am receiving counseling. I understand that my revocation of this General Authorization will not affect a disclosure that Hidden Lakes Counseling has already made under this authorization. I understand that information used or disclosed under this authorization may be subject to re-disclosure by the recipient, and may no longer be protected by Hidden Lakes Counseling’s confidentiality rules.
I authorize Hidden Lakes Counseling and the persons or entities listed below, or their representatives, to mutually release and disclose my health information. I waive any right of privacy that I may have in connection with the disclosures hereby authorized.
This authorization is only valid until ________________________________ [fill in date], or until three months after my file is closed at Hidden Lakes Counseling.
| Name: | Phone Number: | Address: | Client Initials: |
| Name: | Phone Number: | Address: | Client Initials: |
| Name: | Phone Number: | Address: | Client Initials: |
| Signatures |
| Client signature
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Date | Client signature | Date |
| Print name of parent or guardian (if client is under 18) | Print name of parent or guardian (if client is under 18) | ||
| Signature of parent or guardian
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Date | Signature of parent or guardian | Date |
| Witness
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Date | ||