Authorization to Release Confidential Information/Records Request

Authorization to Release Confidential Information/Records Request
Client Name*

First NameMiddle NameLast Name
Other or previous listed names or aliases (including Maiden)*
Client Date of Birth*

MonthDayYear
Date
Client Status*

Active ClientFormer 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.
Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Who is requesting records and/or authorizing the release of confidential information?*

ClientParent/Legal Guardian/Power of Attorney/Legally Authorized Representative
Name of Parent/Legal Guardian/Power of Attorney/Legally Authorized Representative

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Client (proof of legal/custodial relationship may be required)*

ParentLegal GuardianPower of AttorneyOther Legally Authorized Representative
I, the aforementioned client or 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:
Name of Contact/Organization*
Address of Contact/Organization*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Contact/Organization*
Please enter a valid phone number.
Fax Number of Contact/Organization
Please enter a valid phone number.
Email of Contact/Organization
example@example.com
***Please note - if you are requesting that copies or reproductions of clinical/medical records be disseminated either to you or a third party, we will only fulfill this request via Mail, Fax, or Client (or legally authorized representative) pickup.***
Method(s) of Communication Authorized (please check all that apply):*

MailFaxVerbal DisclosureEmail CorrespondenceClient Pickup
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, understood and agree to the terms of email correspondenceI do not wish to correspond via email
Type of Service for which you are authorizing CTS to release confidential information (please check all that apply):*

Individual TherapyCouples TherapyFamily TherapyGroup TherapyPsychiatric
If disclosure of Couples or Family Therapy records is being requested, please list all parties who may have participated in said treatment with you. Please note that there may be some circumstances where records for Couples and/or Family Therapy can only be released if consented to in writing by all parties who participated in the treatment.*
Please list all dates of service to be released:*

All DatesSpecific Date Range
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Types of information to disclose (please check all that apply):*

DiagnosisTreatment PlanTermination SummaryProgress NotesInformation required for referral and coordinationFinancial InformationClinical AssessmentTesting/Evaluation ResultsEntire Patient RecordPsychiatric DocumentationAppointment ScheduleOther (fill in below)
If "Other" indicate below:
The purpose of disclosure is (Please check all that apply)*

Ongoing TreatmentCoordination of ServicesDisability determination/vocational rehabilitationLegalContinuation of CareFinancial PaymentOther (fill in below)
If "Other" indicate below:
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 Individual 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 Individual Initials*
Unless otherwise indicated, this authorization will expire on the following date:

MonthDayYear
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 Client/Parent/Legal Guardian or Authorized Representative*

Clear
Date*

MonthDayYear
Date
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)*

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