Consent to Release Mental Health Records

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I hereby give permission to Tracy Milstead, LPC, for the mutual exchange of all confidential written and verbal Protected Health Information (PHI) between, and from, the agency/business/entity listed below.

Tracy Milstead, MA, LPC
admin@tracymilsteadcounseling.com
Phone: 904-310-4446

Client's Name *

Client's Date of Birth *

YYYY

Business/Entity Name To Send Records *

Address To Send Records *

Phone/Fax/Email of Business/Entity Listed Above *

Information To Be Released: *

Progress Notes

Educational Testing/Plans

Consultation Notes

Intake

Drug and Alcohol Assessments

Mental Health Assessments

Treatment Plans

Discharge Plans/Paperwork

Other:

Required

If checked "Other" above, please write below what other records need to be released:

For the purpose of: *

This is a records request

The continuation of treatment, care, and services

The coordination of treatment, care, and services

Other:

If checked "Other" above, please write below what other purpose:

This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. If not previously revoked, this consent will terminate upon one year from the date of signature on file.

Information released is not to be further disclosed or used for any other purpose other than that stated in this authorization. It is understood that I have the right to revoke this consent in writing at any time. Any revocation shall be in writing, signed by me, and the signature witnessed by a person who can attest to my identity. No written revocation of consent shall be effective until it is received by the person otherwise authorized to disclose records, and shall have no effect on disclosures made prior thereto. I understand I have the right to inspect and copy the information released. I further understand that my refusal to consent to the release of the information specified above will prevent disclosure of such information to the facility or person named herein for the stated purpose.

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.”

Client or Guardian Signature *

Today's Date *

YYYY

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