IBH Authorization

I hereby authorize

Client Name

EAP Provider Name

Address

Telephone

to disclose records and information obtained in the course of EAP Services to Integrated Behavioral Health and its authorized employees

I hereby authorize Integrated Behavioral Health and its authorized employees to provide the above-named provider with the information needed to determine the necessary and appropriate services.

Client Name

I understand that I can limit my disclosure to specific types of information and have noted disclosure limitations as follows

No disclosure limitations

Disclosure limited to the following types of information

Client's Initials

I understand that I can revoke this consent at any time, except to the extent that action has been taken in reliance of this consent prior to my revocation. I understand that this authorization will expire two years after the date of my signature, or, if not earlier revoked, it shall terminate on:

Event, Date, or Condition

I also understand that I have a right to a copy of this authorization

Client Name

Signature of Client, Parent, Guardian, or Authorized Representative of Client

clear

Date +

Subscriber SS #