Form ~ Authorization-Release of Information

The Esposito Institute, Inc.
Benita A. Esposito, MA, LPC

Authorization for Release of Protected Health Information


Client Name:______________________________________

Date  _________________  Birth date:___________

I authorize Benita A. Esposito, MA, LPC, 63 Pleasant Hill Road, Blairsville, GA 30512 to:

____ Exchange
____ Release
____ Obtain

The following information: Only that information checked below will be included in this release of information:

____ Intake, Diagnosis & Treatment
____ Brief Summary of Assessment & Treatment (written and telephone)
____ Discharge Summary
____ Other (Specify)________________________________________

To/With/From:

Name: ______________________________________

Phone: ______-______-________

Facility: ________________________________________

Fax: ______-______-________

Address: _______________________________________
                      Street                    City            State        Zip
 
This information is requested for the purpose of:
____ Continuity of Care 
____ Other (specify)  __________________________________

This authorization shall remain in effect for the duration of treatment unless an expiration date is specified. ______________.

You have the right to revoke his authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that Benita Esposito has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I, the client, understand that my counselor generally may not condition counseling services upon my signing an authorization unless the counseling services are provided to me for the purpose of creating health information for a third party.

I, the client, understand that information used or disclosed pursuant to the authorization my be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.

________________________________________________
Client Signature                                                           

_____________________
Date


________________________________________________
Signature of Parent or Guardian (If appropriate)             

_____________________
Date
 

 


We gain strength, and courage, and confidence by each experience in which we really stop to look fear in the face ... we must do that which we think we cannot. ~ Eleanor Roosevelt