AUTHORIZATION FOR THE USE AND DISCLOSURE

OF PROTECTED HEALTH INFORMATION-

ALL DIVISIONS OF EMBERHOPE INCLUDING FCS COUNSELING, STRIVE, AND YOUTHVILLE

NAME OF INDIVIDUAL:

Last / First / Middle / Birthdate / ID Number
In order to enhance care and treatment, coordinate services, and/or meet billing, educational, or legal requirements, I authorized EmberHope, Inc.:
FCS Counseling / 4505 E 47th St S, Wichita KS 67210
EmberHope Division/Program Name / Address (Street, City, State, ZIP)
To RELEASE or To OBTAIN the following information for the individual named above:
(Please check each & every applicable item)
Mental Health Information (Other than therapy notes) / Consultation Reports
Admission Evaluation/Assessment / Diagnostic Reports
Treatment/Care Plans / Educational Reports
Discharge Summary / Legal Reports
Billing Information / Medical Reports
Hospitalization Screens / Progress Reports
Other: / Psychology Reports
Other: / Other:

NAMED ENTITY: This information may be exchanged with the following entity via verbal, email, faxed or written communication:

Individual or Agency Name / Address (Street, City, State, ZIP)

I understand that:

  • This authorization will expire (select one)

One year from date of signature -- or -- On the following date or event: ______.

  • I may withdraw my permission for disclosure at any time by notifying EmberHope in writing. I understand that prior actions taken in reliance on this authorization by EmberHope or the other named entity that had permission to access the individual’s health information will not be affected.
  • That information used or disclosed as a result of this authorization may be re-disclosed by the recipient and may no longer be protected by law.
  • I amnot required to sign this authorization in order to receive treatment, benefits or eligibility.
  • A photocopy of this document is as valid as the original.
  • By signing this authorization, I indicate that I have read it and agree to the uses and disclosures of the information as described.

SIGNATURE:

X
Signature of Individual or Individual’s Legal Representative / Relationship / Date
X
Signature of Witness / Date

HIPAA Authorization For Use General Disclosure FORM 020116.Docx