Authorization for Release of Behavioral Health and/or Medical Information
Contact Name: Life Solutions Psychotherapy
Program Address: 20 Arcampus Drive Rochester, New York 14612
Phone: (585) 225-9720 Fax: (585) 225-6898
TYPE OF RECORDS REQUESTED:
One-time Use/Disclosure: I authorize the one-time use or disclosure of the information described above to the
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.
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.