HIPPA RELEASE FORM

Please fill out the following form. You will receive a copy of your completed form and a copy of our HIPPA Privacy Rules via email.

Our HIPPA Privacy Rules can be downloaded here.

If you need an offline copy of this form, please click here.

HIPAA Release for Assessment and Treatment
**Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**
I, the undersigned, am requesting counseling and / or consultation services by:

Whole Hope Christian Counseling, LLC (EIN: 81-4201353)

This authorizes Whole Hope Christian Counseling and those there under, to provide consultation, counsel and referral services. I have been informed of the nature and purposes of this service, and that my consent can be revoked in writing prior to, and/or during the consultation period.

I have read and fully understand the above authorization for counseling/consultation. No guarantee of assurance has been made to me as to any of the results that may be obtained from these services. This is a release of any and all liability to Whole Hope Christian Counseling and those under the practice from any decisions or actions that I may or may not take as a result of the counseling I receive from this practice.
Full Name*
Email*
I authorize  _____________________________ to use and disclose the protected health information described below to Whole Hope Christian Counseling, LLC.*
This authorization for release of information covers the period of healthcare specified below:
Date From Date To
OR:
- All past, present and future periods.
I authorize....*
- The release of my complete health record (including records relating to mental health care, communicable diseases, and treatment of alcohol or drug abuse).
- The release of my complete health record with the exception of the following information:
Extent  of  Authorization*
- Mental health record
- Communicable diseases (Including HIV and AIDS)
- Alcohol/drug abuse treatment
- Other (please specify)
Please specify*
1. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
2. I understand that I have the right to revoke this authorization in writing at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
3. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
4. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Client's Signature:*
Signature of Parent or Guardian if client is under 18:
FURTHERMORE, I have received a copy of this contract and have read the HIPAA policy as required by law.
Client's Signature:*
Signature of Parent or Guardian if client is under 18:
Today's Date*
Name
This field is for validation purposes and should be left unchanged.

HIPPA RELEASE FORM

HIPAA Release for Assessment and Treatment

View Our Services

Counseling Services
Yoga Studio
“The Tribe”

HIPPA RELEASE FORM

HIPAA Release for Assessment and Treatment

View Our Services

Counseling Services Yoga Studio “The Tribe”

Counseling Services
Yoga Studio
“The Tribe”