Lucid Listening

Authorization to Share Information

PAGE EIGHT

PRINT NAME OF CLIENT: ______________________________________________

PRINT NAME OF PARENT/GUARDIAN, IF RELEVANT: _______________________________________________

This form, when completed and signed by you, authorizes me to release protected information from your clinical record to the person/ agency you designate. PLEASE PRINT LEGIBLY

I authorize Dr. Dev Chilson to release the following:

ASSESSMENT AND TREATMENT INFORMATION INCLUDING DIAGNOSES, RECOMMENDATIONS, AND CHEMICAL DEPENDENCY ISSUES________ Initial Here        OR

Provide your own detailed description of information you would like shared from your file. _____ ____________________________________________________________________

This information should only be released to: (Provide name and address/FAX # of person or organization to whom the information is to be released)_____________________________

___________________________________________________________________

I am requesting Dr. Chilson to release this information for the following reasons:

To coordinate treatment___ To coordinate other services____ Other Reason  _______________

___________________________________________________________________

This authorization may be revoked at any time. The only exception is when action has been taken in reliance on the authorization. (This means that if the information has already been released, it can't be “un-done.”)

Unless revoked earlier, this authorization will expire 180 days from the date of signing, or shall remain in effect for the period reasonably needed to complete the request. If you would like to limit this authorization to less than 180 days, state the date you would like it to expire:________________

I understand that Dr. Chilson generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. (This means that, in general, I may not refuse services to you if you do not sign, unless the main reason for your visit is to provide information to a third party.)

I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of my information and no longer protected by the HIPAA privacy rule. (This means that I cannot protect the information once it leaves my office; it may be re-disclosed by others.)


_____________________________                                              ____________________

Signature of Client or Parent/Guardian                                                        Date