Foundations Release of Information - Foundations Counseling by cuiliqing


                                          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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