InSync ROI| Renewal Christian Counseling Center

SECTION 1 OF 6

Patient Information

Please complete the following fields.

Client's First Name*

Client's Last Name*

Date of Birth*

Office Location*

Email*

Address*

SECTION 2 OF 6

Type of Health Information to be Released or Disclosed

Please check all that apply

Request to Release the Following Information:*

Entire Mental Health Record

Diagnosis / Assessments

Psychotherapy Session Notes

Presence/Participation in Treatment

Treatment Plan & Recommendations

Billing Records

Other

Please Specify*

SECTION 3 OF 6

Purpose of Request / Disclosure

Please check all that apply.

Purpose*

AD(H)D Testing

Continuation of Care

Insurance

Legal

Other

Please Specify*

SECTION 4 OF 6

What action should be taken?

Please select an option.

Release Action*

Release a copy of my health information to me.

Release my health information to someone else. I have listed where I would like my health information to be sent in Section 5 below.

SECTION 5 OF 6

Where would you like your information sent?

Please check all that apply.

Release Method*

I would like to have it emailed to me at the email address listed in Section 1.

Please mail it to me at the address listed in Section 1.

Please email it to the email below.

Please mail it to the address below.

Please fax it to the number below.

I authorize the verbal disclosure of information specified in Section 2 to the person or organization listed below.

Person or Organization You're Releasing Information To:

First Name

Last Name

Organization

Phone Number

Fax Number

Address

SECTION 6 OF 6

Important

Health Information sent in an unencrypted email is not secure. The Health Information may be intercepted and seen by others. There are other risks with an unencrypted email including misaddressed or misdirected messages, email accounts that are shared, messages forwarded to others, and messages that are stored on servers that have no security. By choosing to receive your Health Information by unencrypted email, you are acknowledging and accepting these risks. Your name, home address, insurance information, medical information, and other personal information may appear on the records we are sending to you.

This Authorization is valid for one year from the date that I signed unless another date is listed below.
This Authorization is voluntary. My treatment will not be impacted even if I do not sign this Authorization.
My Health Information may include information about behavioral or mental health services, treatment for alcohol and drug abuse.
I may revoke or withdraw this Authorization, except to the extent that action has been taken prior to the receipt of the revocation or withdrawal, by mailing or faxing my written request along with a copy of the original Authorization to the department where my Authorization was made or given.
The information to be released maybe from my electronic health record (EHR). I understand that the data from the EHR are current as of the date printed. I further understand that in reducing the data to paper, information from the electronic database is being reformatted onto paper and the page numbers may reflect the printed document, not actual pages in the EHR.
Once my Health Information is disclosed as requested, it may no longer be protected by federal or state privacy laws and could be re-disclosed by the person(s) receiving it.
If I am not making this request in person, I may be asked to provide a copy of my current driver’s license or state identification.
This release is being made at my request.

Relationship to Client*

Signing Parent / Legal Guardian's Name

Signature*

Date*

Authorization is valid for one year from the date signed unless another date is provided here.

This field is for validation purposes and should be left unchanged.