RELEASE OF INFORMATION

RELEASE OF INFORMATION
I, *

First Name Last Name
Date of Birth *

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Date
AUTHORIZE THE EXCHANGE OF INFORMATION BETWEEN MATTHEW GRANT, PSYD., HSPP AND THE FOLLOWING PHYSICIAN/THERAPIST/ OR OTHER HEALTHCARE PROVIDER: *
Please add the NAME, ADDRESS, CONTACT NUMBER & FAX!
Check ALL that apply: *
The purpose of the Disclosure is: *
This consent will expire at the end of 60 days or as specified here:

Month Day Year
Date
I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I have the right to revoke this authorization, in writing, at any time by sending such written notification to NorthStar Psychological + Consultation Services, LLC office address. However, my revocation will not be effective to the extent that NorthStar Psychological + Consultation Services, LLC has taken action on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed after the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule, and NorthStar Psychological + Consultation Services, LLC is not responsible for any subsequent disclosure. I understand that my psychotherapist generally may not condition treatment services upon my signing an authorization unless the psychotherapy services are provided to me for the purpose of creating health information for a third party.
Signature *

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Date *

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