Release of information | Mesa Valley Counseling

This form is sent over a secure connection. Please do not complete it on a shared or public computer.

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Client whose information may be exchanged

This authorization lets Jason Cheney, M.Ed., LPC send, receive, and exchange protected health information with the people or organizations you name below. Add as many recipients as you need on this one form. It is written to meet common HIPAA authorization elements and Colorado confidentiality rules. It is not a general medical release.

Last name *

First name *

Middle name

Date of birth *

Name of person signing this authorization *

I am signing as *

People or organizations

Name each individual or entity that may send information to, and receive information from, this practice. Use Add another person or entity if you need more than one release.

Person or organization 1

Name / agency *

Address

Phone

Secure email or fax

Direction of exchange *Mesa Valley Counseling may send information to this person or organizationMesa Valley Counseling may receive information from this person or organization

Purpose of the disclosure *

Add another person or organization if you need more than one. The first stays on the page.

Information that may be exchanged

Initial only what is needed. More specific authorizations are stronger legally and clinically.

Type of information *Mental health evaluations and assessmentsMental health diagnosisPsychological testing or assessmentsTreatment planCourse of treatment and attendanceAppointment dates and schedulingSubstance use information or history (42 CFR Part 2)Other (describe below)

If other, please specify

I understand psychotherapy notes, if any are kept separately, are not included unless I specifically write that request in the “other” field above.

Your rights and required notices

Communications in therapy are protected under federal and Colorado law (including C.R.S. § 12-245-220) and generally cannot be disclosed without written authorization, except for danger to self or others and abuse or neglect of children or at-risk adults. Substance use records, if included, are also protected by 42 CFR Part 2 and may not be redisclosed without a further specific authorization. Signing this form is not a condition of treatment, payment, enrollment, or eligibility unless a court or authorized third party has required treatment. Information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by HIPAA. You may revoke this authorization in writing at any time, except to the extent action has already been taken. A photocopy or electronic copy is as valid as the original. You are entitled to a copy of the signed form.

If I marked substance use information, I specifically authorize release of those records and understand 42 CFR Part 2 redisclosure limits.

I understand redisclosure by the recipient may occur and that HIPAA may no longer protect the information after it is sent. *

I am signing freely. Treatment is not conditioned on this authorization except where legally required. *

Expiration and signature

This authorization expires *

One calendar year from the signature dateOn the end date I enter belowWhen the stated purpose is completed, and no later than one year from today

Effective from (optional)

Effective to (required if you chose a specific end date)

Relationship to client (if not the client)

Typed legal name *

Date *

Signature of client or parent/legal guardian *

Type your full legal name. Checking the box applies your electronic signature. This page does not record handwriting, a mouse path, or a finger tracing.

Typed legal nameI agree that typing my name is my electronic signature. It has the same legal effect as signing on paper under the federal ESIGN Act and the Colorado Uniform Electronic Transactions Act.

Sign by typing your legal name and checking the consent box, then submit the form.