Release of Information

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Please complete if you wish to have your records shared with this provider, or have this provider share your records with others. If you do not want the therapist to coordinate care with others, there is no need to complete this form.

Email *

Client Name

Client's Date of Birth

YYYY

I hereby grant permission for Heather Moller, LCSW to share or receive information relevant to the care of the above named individual via mail, email or other means from/to the following entity (list person/agency, address, phone number, email, fax if applicable).

This disclosure may include the following types of information (check all that apply):

Psychological Evaluation

Psychiatric Evaluation

Psychological Testing or Screening

Diagnosis

Treatment Plan

Progress Notes

Other

All of the above as relevant

The purpose of this disclosure is (check what applies):

Care coordination/continuity of care

Referral for additional treatment/service

Client request

Other:

If you checked "other" for Type of Information to be disclosed, or Purpose of Disclosure, please use this space to describe the type of information or purpose you are seeking.

If not revoked, this consent for release of information shall remain in effect until the following date, or for one year, whichever is sooner:

YYYY

I understand that I am consenting to have my protected health information shared for the purposes named above. I understand that I can revoke this consent at any time, by notifying Heather in writing of my desire to do so. I understand that revocation will not be retroactive. I understand depending on who will receive this information, that individual or entity may not be governed by HIPAA law and therefore may not be prohibited from sharing it. I understand that it is my responsibility to know the limits of confidentiality imposed on the entities involved in my decision to share my information.

I have read the above and all questions have been answered to my satisfaction.

Clear selection

By checking the box below, I affirm that I am consenting to the use of electronic signatures for convenience, and that my e-signature shall carry the same legal weight as a traditional handwritten signature.

I affirm consent to use my electronic signature.

Signature (name of client/legally responsible party)

Date of electronic signature:

YYYY

A copy of your responses will be emailed to the address you provided.

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