Authorization to Release Confidential Information / Records Request

Please fill this section out with the information of the individual for which records and/or release of information are being requested.

Client First Name *

Client Middle Name *

Client Last Name *

Other or previous listed names or aliases (including Maiden)

Date of Birth * +

Client Status: *

Active Client

Former Client

To submit a request to Christian Theological Seminary Counseling Center (CTS) to disclose any confidential information, this form is to be filled out, signed, and submitted with a clear copy of a valid photo ID of client and/or the authorized representative. This form must be completed for each individual Contact or Organization to whom you are requesting CTS to disclose protected health information.

Legal guardianship, power of attorney, or other authorized representation documentation must be provided, if applicable.

**Minors under 18 years of age must have a parent or legal guardian sign to authorize any release of information. Individuals 18 years old or older are considered adults and therefore must consent to the release their own records unless under legal guardianship or other authorized representation for which proof of this relationship may be required.

If you are requesting that physical records be disseminated, please allow a minimum of 14 business days to process your request, but understand additional processing time may be necessary. We will not confirm or deny any request or disclose any client protected health information (PHI) without a completed authorization to release confidential information unless mandated by law.

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Please complete this section with the information of the individual who is completing this form and is authorized to request records and/or release of information for the aforementioned client.

First Name of Person Requesting Records *

Middle Name of Person Requesting Records *

Last Name of Person Requesting Records *

Date of Birth * +

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Relationship to Client listed above (if you are the client, write "Self") *

I, the aforementioned individual who is authorized to request records and/or release of information for the aforementioned client, am requesting Christian Theological Seminary to… Please check all that apply *

release to:

obtain from:

exchange information with:

Contact/Organization *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Fax Number

Method of Communication Authorized (please check all that apply) *

Mail (you are requesting physical records to be disseminated)	Fax (you are requesting physical records to be disseminated)	Verbal Disclosure	Email Correspondence
Client Pickup	Third Party Request Pick up ( Not Currently Available)

If you choose to permit contact by email, your signature also indicates that you are allowing Christian Theological Seminary/your counselor to contact you via emails, to respond to emails, retain your email address and contact information, and that you will not hold your counselor and/or Christian Theological Seminary responsible for any difficulties resulting from email communication. By agreeing to email communications, it is understood there is always the possibility that unauthorized persons may attempt to discover your personal information. CTS takes every reasonable precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communication could not occur. (If patient is a minor or has a legal guardian, communication described above is assumed to be conducted between the counselor and/or CTS and parent/legal guardian). *

I have read, understand and agree to the terms of email coorespondence.

I do not wish to coorespond via email.

Type of Service for which you are authorizing CTS to release confidential information(please check all that apply) *

If Couples or Family Therapy disclosure is being requested, please list those who potentially participated in therapy with you (providing this information does not release and/or confirm any attendance in services) *

Please list all dates of service to be released *

All	Date Range

From * +

To * +

Type of information to disclose (Please check all that apply) *

The purpose of disclosure is (Please check all that apply) *

Only records originated through CTS Counseling Center facility will be copied. I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing, and present my written revocation to CTS. I understand that the revocation will not apply to information that has already been released in response to any records authorized prior to the revocation submission. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

Client/Authorized Initials *

I understand that my completion of this form to release confidential health information is voluntary and that I may refuse to complete this form. I also understand that I am not obligated to sign this form as a condition of treatment at the CTS Counseling Center. I understand that I may inspect or obtain a copy of the information to be used or disclosed. I understand that any disclosure of information carries with it the potential for an unauthorized disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

Client/Authorized Initials *

Unless otherwise indicated, this authorization will expire on the following date +

If I fail to specify an expiration date above, this authorization will expire 60 days from the date signed.

I have read the conditions of this form outlined above and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

Signature of Patient / Parent / Legal Guardian or Authorized Representative *

clear

Date * +

Printed Name of Legal Guardian or Authorized Representative *

Relationship to Patient *

Address, City, State, Zip of Authorized Representative *

Phone Number *

Please upload the following:

A clear copy of a valid photo ID or ID's (Include ID of owner of records, legal guardian, and/or authorized representative)

Legal guardianship and/or authorized representative documentation (If applicable)

For third party request you may upload any signed authorizations or supporting documents here. *

Form updated: *

Individual Therapy	Couples Therapy	Family Therapy	Group Therapy
Psychiatric	All of the Above

Diagnosis	Clinical Assessment
Treatment plan	Testing/Evaluation Results
Discharge summary	Entire Patient Record
Progress Notes	Psychiatric Documentation
Information required for referral and coordination	Appointment Schedule
Financial Information	Other Other

Ongoing treatment	Legal
Coordination of services	Continuation of Care
Disability determination/vocational rehabilitation	Financial Payment
Other Other