Release of Information (1) "*" indicates required fields Today's Date* Month Day Year Individual Receiving ServicesIndividual's Name:* First Last Individual's Date of Birth* Month Day Year Individual's Policy NumberIndividual'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 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 Case Coordination Other (describe below) Other (Description)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. 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 information:Still Waters Professional Counseling Services, Inc. may share or provide information with the following entities labeled "B".B_1B_1) Description Primary Care Doctor Psychiatric or Behavioral Health Provider Other Doctor (Specialist) School Employer Other (B_1) Company/Organization/Person(s) Name:*(B_1) Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (B_1) Phone:(B_1) Fax Number:B_2B_2) Description Primary Care Doctor Psychiatric or Behavioral Health Provider Other Doctor (Specialist) School Employer Other (B_2) Company/Organization/Person(s) Name:(B_2) Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (B_2) Phone:(B_2) Fax Number:B_3B_3) Description Primary Care Doctor Psychiatric or Behavioral Health Provider Other Doctor (Specialist) School Employer Other (B_3) Company/Organization/Person(s) Name:(B_3) Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (B_3) Phone:(B_3) Fax Number:B_4B_4) Description Primary Care Doctor Psychiatric or Behavioral Health Provider Other Doctor (Specialist) School Employer Other (B_4) Company/Organization/Person(s) Name:(B_4) Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (B_4) Phone:(B_4) Fax Number:B_5B_5) Description Primary Care Doctor Psychiatric or Behavioral Health Provider Other Doctor (Specialist) School Employer Other (B_5) Company/Organization/Person(s) Name:(B_5) Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (B_5) Phone:(B_5) Fax Number:Provide or Request Information AuthorizationI consent to the release of information:* (A) (Still Waters) may REQUEST information from (B) (any listed above) and (B) may PROVIDE information to (A), and in reverse, (B) may REQUEST information from (A) and (A) may PROVIDE information to (B).Consent Withdrawal* I understand that I can withdraw this release of information at anytime.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: Month Day Year Consenting SignatureWrite A NoteSTOP AND SUBMIT FORM BELOWThis next section for Still Waters Internal use only.Witness Signature/CredentialsWitness Signature Date: Month Day Year Witness Printed Name/Credentials First Last Credentials Δ
