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.