Release of Information (1)

Today's Date

Individual Receiving Services

Individual's Name:
Individual's Date of Birth
Individual's consent status:
Parent or Legal Guardian Name:
Consent:
I consent that I am legal to make decisions on this release of information behalf of

Authorization

I HEREBY REQUEST AND AUTHORIZE …
… the following Provider/Holder and Requester of information consisting of individuals/agencies/organizations/ schools/ and or companies to obtain, disclose and verbally discuss Medical/Clinical/Criminal/Scholastic records including: Treatment Plans, Progress notes, Diagnoses, Psychological Testing, Medical Info/Labs, Medication Lists, Criminal Records, Drug and Alcohol Screenings, Scholastic Records, Discipline Records, Comprehensive Assessments, Discharge Summaries, Psychiatric Evaluations, Crisis Intervention Assessments and other with each other for the purpose of: (select all that apply)
I understand that the Federal Privacy Rule (HIPPA) …
… does not protect the privacy of information if disclosed and therefore request that all information obtained from this individual or agency be held strictly confidential and NOT to be further released by the recipient. I further understand that my eligibility for benefits, treatment or payment is not conditioned upon my provision of this authorization. I intend this document to be valid authorization conforming to all requirements of the Federal Privacy Rule and understand that my authorization will remain in effect for:

Provider/Holder/Requester (A) Information:

Still Waters Professional Counseling Services, Inc. (Still Waters) • 3711 Executive Center Dr. • Augusta, GA 30907 • Phone: 706-655-9224 • Fax 706-955-9349

Provider/Holder/Requester information:

Still Waters Professional Counseling Services, Inc. may share or provide information with the following entities labeled "B".

B_1

B_1) Description
(B_1) Address:

B_2

B_2) Description
(B_2) Address:

B_3

B_3) Description
(B_3) Address:

B_4

B_4) Description
(B_4) Address:

B_5

B_5) Description
(B_5) Address:

Provide or Request Information Authorization

I consent to the release of information:
Consent Withdrawal
Signature consent status:
Signature Date:

STOP AND SUBMIT FORM BELOW

This next section for Still Waters Internal use only.
Witness Signature Date:
Witness Printed Name/Credentials