AUTHORIZATION: RELEASE or EXCHANGE PROTECTED HEALTH INFORMATION "PHI"

I, *

hereby authorize

My Serenity Mental Wellness (MSMW)

to release confidential information obtained during the course of my treatment to [name or function of the person(s) or entities to whom information is to be released]

Client Home Address: *

Client Phone #: *

Date of Birth: * +

Recipient Address: *

Recipient Phone # *

Recipient Email #: *

This Authorization permits the release of the following information: *

I authorize the release of the information described above for the following purpose(s): *

The specific uses and limitations on the types of information to be released are as follows: *

The specific uses and limitations on the use of the information by Recipient are as follows: *

The Authorization shall remain valid until: * +

By completing and signing this form, you are authorizing the use and/or disclosure of individually identifiable health information (referred to here as Protected health Information “PHI”), as identified below and consistent with California and federal laws governing the privacy of such information.

By: *

Signature: *

clear

Date: * +

Provider: *

Signature: *

clear

Date: * +

CLIENT RIGHTS

● Client understands this Authorization is completely voluntary and if signed it is under their own accord. And client’s treatment is not affected by the decision to sign or not sign.

● Inspection or a copy of this Authorization form is available at client’s request to the extent permitted by law.

● Revocation of this authorization is available to the client by providing a written notice to the provider (Section 56.15). Revocation will take effect immediately upon the provider receiving written notice.

● Please be aware that My Serenity Mental Wellness (MSMW) may not be able retrieve any information that has already been released as authorized by you previously.

● There are exceptions to the requirement of having a written authorization as per section 56.10 (b). MSMW must comply with the disclosure of information when complying with a court order or search warrant, among other things.

Diagnosis	Treatment Plan	Progress to Date
Clinical Test Results	Physical Exam	Prognosis
Dates of Treatment	Psychiatric Evaluation	Medical Records
Educational Reports	Initial Assessment	Any and all Information Necessary
Other (Specify) Other (Specify)