Jessica H. Thiede, Psy.D. Licensed Clinical Psychologist 3414 Edwards Road, Suite 5 Cincinnati, Ohio 45208 (513) 490-6320 (513) 386-8489 fax Dr.firstname.lastname@example.org www.drjessicathiede.com Release of Information Re: ________________________________________ Date of Birth: ___________________________ The following information may be released or reviewed: Academic Records Case Summary Closing Summary Diagnosis Doctor Orders Psychological Tests Treatment Plan Psychological/Consultation Reports Collaboration Drug/Alcohol Treatment Information Other ________________________________________________________________ All Information Listed Above I, the undersigned, do hereby give authorization to release protected health information and records regarding the above named client to Jessica H. Thiede, Psy.D. I also give Jessica H. Thiede, Psy.D., permission to release information to the below named party, as she believes is indicated. _________________________________________________ Name and Professional Title _________________________________________________ Address _________________________________________________ Telephone/Fax Patient Rights: You are required to sign this form as a condition of treatment and transmission of health protected information. Information that is disclosed by Jessica H. Thiede, Psy.D., to allied professionals may be re-disclosed by them and is not protected by this document. You do not have to agree to this request to use or disclose your information. You can end this authorization through written correspondence to Jessica H. Thiede, Psy.D. Client Authorization: I, the undersigned, do understand that I may revoke this consent any time except to the extent that action has been taken in reliance upon it. I also understand that this consent will expire six months from the date of this signature unless another date is specified. I have read and understand this information and give my permission to release information relevant to my diagnosis, treatment, and protection of self and others. _________________________________________________________ ________________________________________ (Patient or Patient’s Authorized Representative’s signature) (Date) Notice to Recipient of Information This information is being disclosed and/or received from records where confidentiality is protected by Federal Law including CFR42. Federal regulations prohibit you from making further disclosure of this information except with specific written consent from the person to whom it pertains. A general authorization for the release of clinical or other information is not sufficient for this purpose. Federal rules restrict any use of the information to criminally investigate or prosecute an alcohol or drug abuse patient. The information used or disclosed as a result of this authorization may be subject to redisclosure by the person or entity receiving such information, and thus is no longer protected by the state/federal privacy regulations, including the HIPAA Privacy Rule.
Pages to are hidden for
"release of information"Please download to view full document