Foundations Counseling & Consultation Services, LLC 500 Abernethy Road, Suite 6 Oregon City, OR 97045 (503) 953-5769 Authorization for Exchange/Release of Confidential Health Information Client Information I authorize Foundations Counseling & Consultation Services, LLC to exchange/release information about: Name: _________________________________________________________ DOB: ________________________ Address: _____________________________________________________________________________________ Agency/Organization/Individual Information To: __________________________________________________________________________________________ Address: _____________________________________________________________________________________ Phone: _________________________________________ Fax: _________________________________________ Authorized Information (initial): _____ Mental Health Information _____ Alcohol & Drug Information Check HOW MUCH information to be disclosed: _____ 6 mo. _____ 1 year _____ 2 years _____ ALL WHAT TYPE of information to be disclosed: _____ Emergency Notification Information _____ Assessment _____ Treatment Plan _____ Progress Notes _____Discharge Summary _____ Verbal Exchange Only _____Other: ___________________________________________________________________________ Purpose of Disclosure: I authorize Foundations Counseling & Consultation Services, LLC to exchange/release my confidential health information for the purposes of evaluation, treatment planning, service coordination, monitoring, and treatment referral. I understand that Foundations Counseling & Consultation Services, LLC cannot guarantee information will not be disclosed if the information is released to an organization NOT SUBJECT to Federal and State Laws. Term: I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance upon it. Without my express revocation, this Authorization will expire 1 year from the date of signing or shall remain in effect for the period reasonably needed to complete the request. I have read and understand the terms of this Authorization and I have had an opportunity to ask questions about the use and exchange of my confidential health information. By my signature, I hereby knowingly and voluntarily authorize Foundations Counseling & Consultation Services to release or exchange my health information in the manner described above. _________________________________________________________ __________________________ Signature of Client Date _________________________________________________________ __________________________ Signature of Parent/Guardian Date To those receiving information n under this authorization: This information disclosed to you is protected by state and federal law. You are not authorized to release it to any agency or person not listed on this form without specific written consent of the person to whom it pertains unless authorized by other laws.
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