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Release of Information

Authorization form

Release of Information Form

I hereby authorize Leaders For Life Inc. (“Provider”) to disclose to (name and/or function of the person or entity to whom disclosure is to be made)

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Please enter the name of the person, persons, doctor, group, etc... who will receive your information. This is the "Recipient."

The following protected health information for

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Please enter your name or the client's name and date of birth.

Name of Your Therapist

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Please enter the name of your therapist at Midwest Recovery and Wellness.

What information are you authorizing the release of?

Entire File

Diagnosis

Prognosis

Modalities & Frequencies of Treatment

Session Start/Stop Times

Symptoms

Clinical Test Results

Dates of Treatment

Other

If you checked "Other" please explain.

I understand that I have a right to receive a copy of this authorization, and that any cancellation or modification of it must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider has taken action in reliance upon it. I also understand that such revocation must be in writing and received by Provider to be effective. I authorize the disclosure of the health information described above for the following purpose:

The specific uses and limitations on the uses of my health information by Recipient are as follows:

I understand that Provider cannot condition treatment upon me signing this authorization. I understand that the health information disclosed pursuant to this authorization may be subject to re-disclosure by Recipient and that the Federal Privacy Rule may no longer protect such information, although the re-disclosure of such information may be protected by applicable Michigan law. Provider is authorized to disclose the protected health information specifically listed above until:

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Authorization Expiration Date (If no authorization expiration date is entered then this agreement will continue indefinitely).

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Filled out by (Client or Client's Representative):

First Name

Last Name

Date

If signed by other than client, please indicate the relationship between catient and his/her Representative:

By clicking you are submitting your signature with the above document and agree to all of the above.

Agree

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