General Release for Coordination of Care Form - Shurmatz Counseling, LCSW, PC

Shurmatz Counseling, LCSW, PC
Authorization for Disclosure of Health Information

Coordination of care

Patient Name *

Date of Birth *

Phone *

Address *

City *

State *

Zip Code *

I authorize the use or disclosure of the above-named individual’s health information as described below. Shurmatz Counseling, LCSW, PC and the following physician’s office are authorized to disclose information to each other:

Name of Doctor/Institute *

Layout

Phone Number *

Fax Number *

Address *

City *

State *

Zip Code *

The type and amount of information to be used or disclosed is as follows:

Complete treatment records
Presence and status in treatment
Diagnosis and current mental status
Demographic information
General process and methods of therapy work
Other (please specify)

Other (please specify)

And specifically, does not include:

Specific details/content of personal history OR details of therapy
Other (please specify):

Other (please specify):

This information may be disclosed for the purpose of coordination of care I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to Anna Shurmatz, LCSW-R. This authorization will expire:

In Days *

days or

Or Days *

days following the end of treatment, as indicated. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules.

I will be signing this Patient Information Form as the: *

Patient's Name *

Patient's Signature *

Date *

Patient's Signature *

Clear Signature

Patient's Signature *

Click or drag a file to this area to upload.

If the patient is a minor or unable to sign, please complete the following: *

How old is the patient *

Reason on why patient is unable to sign *

Authority of representative to sign on behalf of the patient: *

Other Authority *

Name of Authorized Representative *

Signature of Authorized Representative *

Date *

Authorized Representative's Signature *

Clear Signature

Authorized Representative's Signature *

Click or drag a file to this area to upload.

PLEASE NOTE: This information has been disclosed to you from confidential records protected from disclosure by state and federal law. No further disclosure of this information should be done without specific, written and informed release of the individual to whom it pertains or as permitted by state law and federal law. 42 CFR, Part II

Shurmatz Counseling, LCSW, PC
Authorization for Disclosure of Health Information

days or

About Shurmatz Counseling

Cheektowaga Office

Amherst Office

West Seneca Office

Shurmatz Counseling, LCSW, PC Authorization for Disclosure of Health Information

days or

About Shurmatz Counseling

Cheektowaga Office

Amherst Office

West Seneca Office

Shurmatz Counseling, LCSW, PC
Authorization for Disclosure of Health Information