Release of Information

Release of Information

Christian Heart Counseling

1751 Tower Drive West Stillwater, MN 55082 (651) 439-2059

Counselor Name

Authorization*

I authorize Christian Heart Counseling to:

Disclose information to
Obtain information from
Exchange information with
Notify Physician

Agency Name*

(the person/clinic who is receiving or sending CHC the information)

Agency Address

Street Address Address Line 2 City State ZIP Code

Agency Phone Number*

Agency Fax Number

Individual Name (Your Name or Minor Name)*

First Name Last Name

Client Date of Birth*

My relationship to the Client is:*

Myself
Daughter/Son
Other

If other, please specify

The information to be disclosed includes*

Purpose of Release*

Coordination of Care
Discharge and Continuation of Care
Client Request
Insurance
Litigation/legal purposes
Other

If other, please specify

I understand the information to be released may include records related to behavior and/or mental health care, alcohol and drug abuse treatment, HIV/AIDS, and genetics. This authorization may be revoked at any time except to the extent that action has been taken in reliance upon it. Revocation must be made in writing to the provider/facility releasing the information. The provider/facility will not condition treatment on whether I sign the authorization. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal law. I understand that this consent will automatically expire without my express revocation upon fulfillment of the above stated purpose or one year from this date, whichever is sooner. I have the right to receive a copy or review information to be disclosed, if requested. Once the records are released to the name above, the clinic or hospital releasing my records cannot prevent them from being shared with a third party. At that point, the records may no longer be protected by state and federal privacy laws.

Write your name as your electronic signature:*

Date*

Send records to*

Christian Heart Counseling

1751 Tower Drive W STE 200 Stillwater 55082
13911 Ridgedale Dr STE 460 Minnetonka 55305
12940 Harriet Ave S STE 215 Burnsville 55337
7362 University Ave NE STE 307 Fridley 55432
1360 Energy Park Drive STE 330 St Paul, MN 55108
616 Currell Blvd, STE190 Woodbury, MN 55125

Fax: 888-675-8262 (all offices)

Christian Heart Counseling

Office Locations

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Insurance We Accept