release of information by 7Bhb5r


									                                                                             Jessica H. Thiede, Psy.D.
                                                                                   Licensed Clinical Psychologist
                                                                                            3414 Edwards Road, Suite 5
                                                                                                 Cincinnati, Ohio 45208
                                                                                                         (513) 490-6320
                                                                                                     (513) 386-8489 fax
                                              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
   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



                                                        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.

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