Release of Information

Renewal Life Counseling, LLC

Office: 864-416-4560
Fax: 866-204-1733

Client Information

Client's Name

DOB

Address

City

State

Zipcode

Phone Number or Email

Clinic/Healthcare Provider

Who has the information to be released?

Address

City

State

Zip Code

Phone Number

Fax Number

Receiving Party (Who the information will be released to)

The information requested below will be delivered to the private practice, Renewal Life Counseling, LLC. Practice is virtual only at this time. Mailing address: PO Box 3042, Easley, SC 29641.

Phone: 864-416-4560 Fax: 866-204-1733 Email: info@renewallifecounseling.com

Information to be Released:

Medical Records

Request for client's record for one year prior to signed date of this release; including initial evaluation.

Brief Statement

Regarding client's progress in treatment with healthcare provider

Telephone Communication

Discuss Client Clinical Status

Purpose of Release of Information

Referral to other services Coordination of care Consultation with doctor/other medical professional Transfer of care

Client/Authorized Person's Signature

Date

This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here: ______________. This authorization may be canceled in writing at any time. A photocopy/fax of this authorization will be treated in the same way as an original. Your signature indicates that you have read and understand this form, and authorize release of your information as described above. I understand that I may refuse to sign this authorization and that refusal to sign will not affect treatment. FOR THE RECIPIENT OF THE INFORMATION: If any of the requested records contain information regarding alcohol or drug abuse treatment, it may be protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further use or disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the use or release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

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