Information Release Form - Release of Information Consent Form

JC Christian Counseling

1821 Oregon Pike Suite 212 / Lancaster, PA 17601 / Office: (717) 278-8326 / Fax: 1- 866-285-7198

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Letter from the Director

Employment

RELEASE OF INFORMATION

I,		hereby authorize JC Christian Counseling to:

Agency or Person


Address		Date	[mm/dd/yyyy]

Confidential and privileged information (written and/or verbal) regarding:

			[mm/dd/yyyy]
Client's Name			Date of Birth	Social Security Number

The following mental health information and/or records may be released due to:

and may be used for the purposes of:

I understand that: a) this information may be protected by federal, state or local law, and that I have been informed that I am under no obligation to disclose this information; b) I may revoke this Authorization by notifying JC Christian Counseling in writing at any time, except to the extent that information has already been disclosed by the permission of this authorization. c) This Authorization may be amended at any time and made less restrictive than this consent already in effect; and d) I may receive a copy of this Authorization, and a copy of this Authorization will be provided to the aforementioned person or agency prior to the disclosure of my information. Having read or having had it explained to me, I understand fully the contents and purpose ofthis Authorization.

Click Here to Sign
Client or Representative Signature	Date

My signature above also confirms that the Client received a clear
explanation of this authorization to make an informed decision.

Description of Representative's Authority to Act for Client

This Authorization (written / verbal consent) will expire on whichever comes first.		or one year after the date of execution,
	Date/Event

NOTICE TO RECIPIENT: The aforementioned information is disclosed to you from records whose confidentiality is protected by State and Federal statute. State and Federal regulations limit your right to make any further disclosure of this information without prior written consent of the person to whom it pertains.

NOTICE TO CLIENT: The information hereby released may be subject to re-disclosure by the recipient and may no longer be protected by the rule that requires this Authorization. In addition, Federal regulation prohibits further treatment being conditioned on your signing this Authorization.