Client Individual Record Request

Client Individual Record Request

Kentucky Counseling Center, LLC
Client Name *

First Name Last Name
Date of birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Upload picture ID *

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I authorize Kentucky Counseling Center, LLC to release to following records *

All records Treatment Plan Assessment Psychotherapy Notes
Dates of service you for specific records you are requesting *
Who should these records be released to? *
Email address where KCC should send an encrypted message containing records.
example@example.com
By signinging this document, I understand that the medical record released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above.

If KCC is asking to use/disclose my information, I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, enrollment in any health plan, or payment/benefit eligibility. I may inspect or copy any information used/disclosed under this authorization.

I consent for KCC to release records by encrypted email to the email address provided.
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