INSURANCE CO. INFORMATION Authorization for Release of Behavioral Health and/or Medical InformationPatient Name: Date of Birth: MM slash DD slash YYYY I authorize that the requested information may be released to received from PRIMARY CARE PHYSICIAN NAME Contact Name for Organization/Facility/Program Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneFax I authorize that the requested information may be released to received from Contact Name: Life Solutions Psychotherapy Program Address: 20 Arcampus Drive Rochester, New York 14612 Phone: (585) 225-9720 Fax: (585) 225-6898PURPOSE OF THIS REQUEST: Healthcare Insurance coverage Discharge Planning Housing Disability Determination Personal Other TYPE OF INFORMATION AUTHORIZED: Drug/Alcohol Evaluation and/or Treatment Psychiatric Evaluation and /or Treatment Medical Evaluation and/or Treatment TYPE OF RECORDS REQUESTED:Inpatient: date(s) MM slash DD slash YYYY Outpatient: date(s) MM slash DD slash YYYY Other: date(s) _any and all records MM slash DD slash YYYY SPECIFIC INFORMATION AUTHORIZED: Assessments Progress Notes Laboratory Test Results: Diagnostic Impression Discharge Summary Diagnostic Test Results Treatment Plans Educational Information Treatment summary (include history/physical, laboratory tests & x-ray reports) Select AllOne-time Use/Disclosure: I authorize the one-time use or disclosure of the information described above to the person/provider/organization/facility/program(s) identifiedMy authorization will expire: When the requested information has been sent/received 90 Days from this date Other Periodic Use/Disclosure: I authorize the periodic use/disclosure of the information described above to the person/provider/organization/facility/program(s) identified as often as necessary to fulfill the purpose identified in this document.My authorization will expire: When I am no longer receiving services One year from this date Other I understand that: I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment. I may cancel this authorization at any time by submitting a written request to the Strong Health Program address above, except where a disclosure has already been made in reliance on my prior authorization. If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be redisclosed. If the authorized information is protected by Federal Confidentiality Rules 42CFR, Part 2, it may not be disclosed without my written consent unless otherwise provided for in the regulations. Release of HIV-related information requires additional authorization. If the medical record information is not sent to another care provider there may be a charge for the requested records. SIGNATURE of Patient or RepresentativeRelationship to Patient (if requester is not the patient): Parent Legal Guardian Other