Authorization to Release Information - LifeWorks Resources

Release of Information Authorization

Client's First Name*

Client's Last Name*

Guardian Name

If client is a minor

Client's Date of Birth

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Month*

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Day*

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Year*

Address:

Street*

City*

TN

select*

Zip Code*

Authorization

I authorize the use and disclosure of health information as described below:

Agency/Facility/Person Authorized to Release Information:*

Agency/Facility/Person Authorized to Receive Information:*

Contact Info and Method Authorized to Send Information:*

Health Information to be Used/Disclosed is Limited to the Following:*

Medical Records Summary

Other Reason:*

Information to be released is limited to the following dates:*

Health Information Released is to be Used/Disclosed for the Following Reasons:*

Continuity of Care

Litigation

Court Proceedings

Other

Other Use Reason:*

Please send information to LifeWorks Resources, LLC via:*

Email: lifeworks@lifeworksresources.com

Fax: 731-345-4086

Mail: 1186 Hwy 45 Bypass, Suite D, Jackson TN 38301

Phone: 731-215-0502

Health information identifies you (the patient) by name, and may include other demographic information about you.

I hereby discharge the releasing facility, its agents and employees from any and all liabilities, responsibilities, damages, and claims which might arise from the release of information authorized herein, to include alcohol, durg abuse, communicable disease including HIV status, and/or psychiatric diagnoses compiled during my visit, encounter, or hospitalization, or make copies thereof in accordance with tthe policies of this facility.

Protected Health Information used or disclosed pursuant to this authorization may be subject to the re-disclosure by the recipient and no longer protected by this privacy rule.

This authorization will automatically expire one (1) year after the date below, unless another date is specified.

I understand that I have the right to revoke this authorization at any time, in writing, as stated in the Notice of Privacy Practices, except where the facility has already made disclosures in reliance upon my prior authorization.

Treatment, payment, enrollment or eligibility for benefits may not be conditioned on obtaining authorization if the Health Information Portability Accountability Act prohibits such condition. If conditioning is permitted, refusal to sign the authorization may result in denial of care or coverage.

I understand that there may be a charge for copying of medical records.

I understand that it is LifeWorks Resources, LLC policy is to ONLY release a summary of the records pursuant to the rules/regulations stated below.
As stated in the “RULES OF TENNESSEE BOARD FOR PROFESSIONAL COUNSELORS…”
0450-1-.18 MANDATORY RELEASE OF CLIENT RECORDS.
(1) Upon request from a client or the client’s authorized representative, an individual registered with this board shall provide a complete copy of the client’s records or summary of such records which were maintained by the provider.
(2) It shall be the provider’s option as to whether copies of the records or a summary will be given to the client.
(3) Requests for records shall be honored by the provider in a timely manner.
(4) The individual requesting the records shall be responsible for payment of a reasonable fee to the provider for copying and mailing of the records.

Authority: T.C.A. §§4-5-202, 63-2-101 and 63-2-102.  Administrative History: Original rule filed April 29, 1992; effective June 13, 1992.

Printed Name of Signatory*

Date*

Signature*

Schedule Appointment

Client's Date of Birth

Address:

Authorization