Authorization for the Release of Information

I, fully authorize KC OMHC to release/receive information regarding my Healthcare to:

Name/Agency

Relationship to Client

Address

City, State, Zip

Phone#

Fax#

The information will be communicated via:

Telephone

Fax

Correspondence and is authorized to be communicated both ways:

Yes No

The requested information will be used to help:

formulate OMHC goals

Coordinate treatment across my healthcare team.

I know that this authorization is voluntary, and will not affect my healthcare and payment if I refuse to sign it.

I understand that I may review the requested information, request and keep upon receipt, a copy of this authorization after I sign it.

I understand that the information provided by this request will be held in the strictest of confidence and is to be used only by the professionals on my healthcare team.

This authorization can be cancelled by me at any time, unless a process has already started and its completion depends on this authorization.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Last Four

Date of Birth

Witness

Date

Your information will be encrypted.