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TYPE OF
INFORMATION TO
BE DISCLOSED
I hereby
authorize Lisa
Herr MSW, LICSW
disclose
protected health
information in
therapy.
This
authorization is
for the minimum
information
necessary for
their party
payments.
EXTENT OF
INFORMATION
I am aware that
these records
may contain
information
concerning the
testing,
diagnosis and
sexually
transmitted
diseases and or
substance abuse
services
governed by 42
CFR Part 2,
governed by RCW
71.
PURPOSE:
____At Client
Request
_____Initiating
Treatment
_____Coordinating
Treatment
--------------------------------------------------------------------------------------------------------------------------------
RECIPIENT OF
PROTECTED HEALTH
INFORMATION
Primary
Insurance_______________________________________________Phone___________________
Address________________________________
City___________________State_____
Zip____________
EMPLOYER___________________________________________________Phone___________________
GROUP
NUMBER_____________________________________EMPLOYEE
ID
NUMBER___________
EMPLOYEE_____________________________________INSURED_______________________________
DATE OF
BIRTH_______________________
INSURED DATE OF
BIRTH
________________________
SOCIAL SECURITY
NUMBER_________________INSURED
SOCIAL
SECURITY_________________
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EVOCATION;
DISCLOSURE;
DURATION
Is is my
understanding
that this
authorization
can be revoked
at any time,
except to the
extent in good
faith may have
already occurred
in reliance on
this
authorization.
Unauthorized
redisclosure by
recipient is a
potential risk.
If not
previously
revoked, this
authorization
will
expire_____________________________________________
Specific
Limitation:
Except as to
third-party
payers, this
authorization
does not include
disclosure for
health
services
received more
than ninety (90)
days from date
of last
signature.
SIGNATURE
This
authorization
covers protected
health
information
pertaining to
___________________________________.
My signature
authorizes use
and/or
disclosure of
protected health
information in
accordance with
the foregoing
from the date of
that signature
(initial or
renewal).
I understand
that I have the
right to refuse
to sign this
authorization
and that my
refusal will not
condition
treatment,
payment,
enrollment or
eligibility for
benefits.
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