Hope Psychology Group: IBH Authorization Form

I, (Client Name)

hereby authorize

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, (Client Name)

hereby authorize Integrated

Behavioral Health and its authorized employees to provide the above named provider with information regarding my EAP benefits, and to disclose and discuss all information needed to determine the necessary and appropriate services.

I understand that I can limit my disclosure to specific types of information and have noted disclosure limitations as follows (Check and initial #1 or #2):

No Disclosure Limitations

Disclosure limited to the following types of information

	Client Initials
1	Client Initials
2	Client Initials

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, Patient, Guardian or Authorized Representative of Client) *

clear

Date: * +

(If signed by other than client, indicate legally responsible relationship) *

Subscriber SS #: *