Release of Information "*" indicates required fields Today's Date MM slash DD slash YYYY Individual Receiving ServicesIndividual's Name: First Middle Initial Last Suffix Individual's Date of Birth MM slash DD slash YYYY Individual's Policy Number Individual's consent status: Individual is of legal age of consent. Individual is under the care of a custodial parent or legal guardian. (List name and relationship below) Parent or Legal Guardian Name: First Last Suffix Relationship to the Individual: Consent:I consent that I am legal to make decisions on this release of information behalf of myself the individual listed above AuthorizationI 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) Treatment Education Financial Other (describe below) Other 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: One (1) year from signature date. Start Date: MM slash DD slash YYYY 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 706-955-9349Provider/Holder/Requester (B) information:(B_1) Company/Organization/Person(s) Name:* (B_2) Address: Street Address City State / Province / Region ZIP / Postal Code (B_3) Phone:(B_4) Fax Number:Provide or Request Information AuthorizationI consent to the release of information:*Select all that apply. Note: Typically ALL are selected. (A) (Still Waters) may REQUEST information from (B) (Listed Above) (B) (Listed Above) may PROVIDE information to (A) (Still Waters) (B) (Listed Above) may REQUEST information from (A) (Still Waters) (A) (Still Waters) may PROVIDE information to (B) (Listed Above) Consent Withdrawal* I understand that I can withdraw this release of information at anytime.Consent Signature:*Signature consent status:* I AFFIRM that I am an Individual of legal age of consent. I AFFIRM that I am the legal representative of the individual. Signature Date:* MM slash DD slash YYYY STOP AND SUBMIT FORM BELOWThis next section for Still Waters Internal use only.Witness Signature/Credentials:Witness Signature Date: MM slash DD slash YYYY Witness Printed Name/Credentials First Last Credentials Δ
