Release of Information Form

LMHC will not condition my treatment, payment, enrollment, or eligibility for benefits by signing this authorization. I authorize LMHC to disclose the above stated records to the Name/Organization listed above. I understand this may include information regarding mental health, alcohol/drug use, and HIV records unless initialed below. I do not need to sign this authorization to receive services unless the services are court ordered or are being created solely for a third party. This consent will expire upon fulfillment of its stated purpose or one year from date of signature. I understand that I may revoke this consent by written notice at any time except (1) when legal action prevents revocation (probation, parole, court confinement), or (2) when requested by my insurance company, as the law provides my insurer the right to consent a claim under my policy. Any release made in good faith, prior to receipt of revocation, shall be deemed valid. This release of information must be filled out completely, signed and dated. A photocopy and/or facsimile of this authorization may be treated in the same manner as the original; however, LMHC reserves the right to require an original consent. I understand the protected health information used or disclosed per this authorization may be subject to re-disclosure by the recipient and may no longer be protected. I will receive a copy of this signed form upon request.