Horizons Counseling Services, Inc.,
440-845-9011; fax- 440-845-9013
Authorization to Release Information
Name ___________________________________________ Date of Birth __________________
I authorize __________________________ and Horizons Counseling Services to release to
the person or organization designated in the box below, the following information: __________
_____________________________________________________________________________
I authorize the person or organization designated in the box below to release to ______________
and Horizons Counseling Services the following information: ___________________________
______________________________________________________________________________
Name __________________________________________
Address _________________________________________
City, State _______________________________ ZIP: ___________________
Phone: ____________________________________ Fax: __________________________
I am requesting that this information be released for the following reason(s):
___ Coordination of Treatment ___ Information for Assessment ___ At my request
___ Other: _________________________________________________________________________
This authorization shall remain in effect until:
___ Evaluation and/or treatment are completed ___ This date: ______________________
___ Other (specify): __________________________________________________________________
I understand that I have the right to cancel this authorization by sending written notification to Horizons Counseling Services and/or the party named above. However, I understand my cancellation will not be effective to the extent that Horizons has already taken action regarding the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that the recipient of this information may re-disclose it and that the information will no longer be protected by the HIPAA Privacy Rule. I understand that my psychologist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party.
______________________________ _________________
Signature of Client or Guardian Date