Release of Information

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=90 BGCOLOR="#FFFFFF" TEXT="#080000" background="127015b3.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>Help4Self   Center</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="Help4Self Center"><B>home</B></A></div> <div> <B>Release of Information</B></div> <div> </div> </td> </tr><tr> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Release of Information</I></div> <DIV ALIGN="LEFT"></DIV> <div> <B>David C. Mathis, Ed.D.</B></div> <div> <I><B>Counseling and Psychological Services</B></I></div> <div> 204 W. Hogan Street</div> <div> Tullahoma, TN 37388</div> <div> 931-393-1043</div> <bR> <div> <B>PATIENT DISCLOSURE AUTHORIZATION FORM</B></div> <bR> <div> <B>Patient Name:______________________________________Date of Birth:______________</B></div> <bR> <div> <B>I authorize disclosure of my protected health information only in the specific manner, for the named reason, and to the specific individual(s) described below.</B></div> <bR> <div> <B>Specific description of information to be used or disclosed:     </B></div> <div> <B>______progress notes only</B></div> <div> <B>______progress notes with therapy notes</B></div> <div> <B>______other:__________________________________________________________________________________________________</B></div> <bR> <div> <B>Reason for requested use or disclosure:______________________________________________</B></div> <div> <B>_____________________________________________________________________________________________________________</B></div> <bR> <div> <B>Name or the person or entity to whom this practice will give/obtain my information:__________</B></div> <div> <B>______________________________________________________________________________</B></div> <bR> <div> <B>This authorization will expire on the following date:____________________________________</B></div> <bR> <div> <B>This authorization provides that:</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Arru01cc009500c800000000.png" HEIGHT="13" WIDTH="13" ALIGN="bottom" HSPACE="0" VSPACE="0">I may revoke this authorization at any time, provided that the revocation is in writing to the provider, except if this practice has taken action relying on the consent or if the authorization was obtained as a condition of obtaining insurance coverage.</B></div> <div> <B><IMG BORDER="0" SRC="Arru01cc009500c800000000.png" HEIGHT="13" WIDTH="13" ALIGN="bottom" HSPACE="0" VSPACE="0">Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by HIPAA privacy rules.</B></div> <div> <B><IMG BORDER="0" SRC="Arru01cc009500c800000000.png" HEIGHT="13" WIDTH="13" ALIGN="bottom" HSPACE="0" VSPACE="0">This practice will not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on my providing authorization for the requested use or disclosure.</B></div> <div> <B><IMG BORDER="0" SRC="Arru01cc009500c800000000.png" HEIGHT="13" WIDTH="13" ALIGN="bottom" HSPACE="0" VSPACE="0">I have the right to access my protected health information to be used or disclosure.</B></div> <div> <B><IMG BORDER="0" SRC="Arru01cc009500c800000000.png" HEIGHT="13" WIDTH="13" ALIGN="bottom" HSPACE="0" VSPACE="0">I will receive a copy of this completed and signed authorization form, upon request.</B></div> <bR> <div> <B>Signature:___________________________________________Date:_____________________</B></div> <bR> <div> <B>Relationship to patient(if signed by a personal rep. of patient):____________________________</B></div> <bR> <div> <B>Witness:____________________________________________Date:______________________</B></div> </td> </tr></table></body>