Lifestyle Therapy And Coaching

Release of Information

Release of Information
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This release is authorized to:
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Release to/Receive From:

Release to/Recieve From:
Name
Name
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Last
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IMPORTANT: Your signature below means that you understand and agree to the following:

• I understand that the health information to be disclosed may be subject to redisclosure by the recipient of the health information and no longer protected by federal privacy rules.
• I understand that the health information to be disclosed may include diagnosis and treatment information, including information pertaining to chronic diseases, behavioral health conditions, alcohol or substance abuse, and communicable diseases, including HIV/AIDS.
• I understand that I will receive a copy of this form after signing it. I also understand that a photocopy of this Authorization may be used in place of the original.
• I understand that my ability to employ the services of Lifestyle Therapy & Coaching will not be affected if I do not sign this form.
• If I sign this form, I understand that I may revoke this Authorization at any time by notifying Lifestyle Therapy & Coaching in writing at the address above, but if I do, it will not have any effect on disclosures prior to the receipt of my revocation.
• I understand that this Authorization will expire ninety (90) days after the date set forth below.
• I hereby hold Lifestyle Therapy & Coaching, its employees, directors, agents, and representatives harmless from any and all damages which might result to myself, my representatives, heirs, and/or assigns from my health information being disclosed to my designee above.

It is understood that the duration of this consent will not be longer than would be necessary and reasonable to carry out the purpose or which it is given.

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NOTE TO PARTY RECEIVING INFORMATION: This information has been disclosed to you from records whose confidentiality is protected by federal law which prohibits you from making any further disclosure of information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. (This form meets the requirements of Federal Regulation 42CRF, Part 2.)

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