Medical Records Release Form

Authorization for Release of Medical Records

I consent to unlimited communication regarding my/my child’s assessment interview, psychiatric and psychological records, treatment progress and summaries.

Records:

From

Lifeway Counseling Centers

11161 Kenwood Rd

Cincinnati, Ohio 45242

Phone (513) 769-4600 Fax (513) 769-0304

Attn: Medical Records

Records:

From

Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

This information is considered instrumental to the ongoing evaluation and treatment of this client. Information requested include(s):

Other:

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV) and drug and alcohol abuse, drug-related conditions, and/or alcoholism. I authorize the release or disclosure of this information.

Confidentiality will be maintained within the supervisory-counselor relationship, except when there appears to be imminent danger to you or others. I understand this authorization may be revoked in writing or in person to Lifeway Counseling Centers at any time except to the extent action has been taken prior to revocation.

This consent will expire in sixty (60) days after the date below, or sooner at my election in which case this authorization will expire on

You agree to hold LifeWay Counseling Centers, Inc. harmless from any claim or liability (including, but not limited to, any claim brought under a confidentiality or privacy law) in connection with the release at your request of the information and records described above. Thus, I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Law.

Further, Lifeway will not condition treatment, payment, health plan enrollment and/or plan eligibility on the refusal to sign this authorization; however information will not be released without signature.

I acknowledge that I have read and fully understand this authorization as it applies to me.

Client Name*

First Middle Last

Guarantor Name (if signing on behalf of client)

First Middle Last

Client/Guarantor Signature*

By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Relationship to Patient*

Date*