Authorization for Use or Disclosure of Protected Health Information

Client Information

First Name

Last Name

Client Address

Primary phone number:

Client Date of Birth:

Recipient Information

hereby authorize Forever Hope Counseling & Educational Services, LLC to disclose the individually identifiable health information as described below. I understand that this authorization is voluntary, and I may refuse to sign this authorization.

Description of information to be released - check all that apply:

(Note: If you need a copy of your record, please fill out a record release form.)

Information to be released

Treatment Plan

goals, objectives, planned interventions, etc

Diagnostic Testing

evaluations or results related to

Billing Records

superbills, receipts, payment history)

Progress Notes

goals addressed, progress made, etc

Appointment management

scheduling, rescheduling, cancellations

Other

Name of person/facility to receive medical information:

Phone Number:

Address:

If you selected the option for other, please specify:

Purpose of the use and/or disclosure:

Continuity of care

Collaboration with another healthcare provider

Collaboration with school/teacher

Other

If you selected the option for other, please specify:

I intend for this Authorization to remain in full force and effect until I revoke it in writing. Further, it is my intent that a copy of this Authorization shall have the same effect as the original.

I further understand that I may revoke this authorization at any time by notifying Forever Hope Counseling & Educational Services, LLC in writing at 1162 E. Sonterra Blvd, Suite 130, San Antonio, TX 78258. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.

Authorization and Signature

Client Signature / Legal Guardian

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

Date of Authorization

If signed by a personal representative:

Print your name

Indicate your relationship to the client and/or reason and legal authority for signing.

A Parent

A legal guardian

Your information will be encrypted.