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Authorization for Release of Information Form
Authorization for Release of Information Form
Philadelphia Institute for Individual, Relational & Sex Therapy
Authorization for Release of Information Form
Chris Fariello
2023-02-13T15:14:58-05:00
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I (client) hereby authorize use or disclosure of protected health information about me as described below.
Name
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First
Last
The following specific person or class of persons or facility is authorized to make the requested use or disclosure:
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Specific description of information to be released (and date(s) of service):
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The information to be released will be used for the psychotherapeutic treatment of the client(s) in a manner that is consistently with all ethical and legal guidelines.
I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
I may revoke or withdraw this authorization by notifying my therapist in writing of my desire to revoke it. However, I understand that any action already taken in advance of this authorization cannot be reversed, and my revocation will not affect those actions. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
This authorization will expire on the below date or 1 (one) year after the date of said authorization.
*
MM slash DD slash YYYY
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