Release of Information FormFor Use in Compliance with HIPAA & California Law Client Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Authorization I hereby authorize Behavia Therapy to: * Release Information to Obtain Information from Exchange information with Behavia Therapy can share information with the following: Name / Organization Contact Person * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Fax Number (###) ### #### Email * Purpose of Disclosure: * Continuity of Care Coordination with other Providers Insurance/Billing Legal Purposes School Coordination / IEP Planning Other Information to be Released (Check all that apply) * Diagnostic Evaluation Reports Progress Reports Treatment Plans / Behavior Intervention Plans (BIP) Session Notes Attendance Records School Records / IEPs Other Format of Disclosure * Verbal Communication Written Reports Electronic Records Copies of Documents Expiration This authorization will expire on Date One year from the date of signature, if no other date is specified. MM DD YYYY Or when the following event occurs: Your Rights You have the right to revoke this authorization at any time by submitting a written request to Behavia Therapy, except to the extent that action has already been taken in reliance on it. Your treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this form. Information disclosed may be subject to re-disclosure by the recipient and no longer protected by HIPAA. Signature By writing my full legal name below, I acknowledge that I have read and understand this authorization. I understand that the information released may include health information protected under HIPAA, and that it will be shared only with the parties I have identified for purposes of coordinating care. I also understand that this authorization is voluntary and that I may revoke it in writing at any time, except to the extent that action has already been taken in reliance on it. Parent / Legal Guardian Name * First Name Last Name Relationship to child * Thank you for completing the Release of Information form.
