Permission to Exchange Information

Client Name *

First

Last

My therapist is: *

PERMISSION TO EXCHANGE INFORMATION

I hereby give permission for my assigned therapist at Virginia Counseling Services to communicate with the following agencies and/or individual: *

Agency / Individual

Email

Contact Information for Agency/Individual

Please give information for at least method of communications below.

Phone

Fax

I grant permission for the following information to be exchanged until the closing of this case or one year following the date on this document: *

Other options

Release of Information Consent Terms & Conditions *

I have read and understand my HIPAA rights pertaining to my information.

1. YOUR AGREEMENT

By agreeing to this release form, you give permission for your assigned therapist at Virginia Counseling Services to communicate with the third party (agencies or individuals) you have listed above.

You also acknowledge that the consent is active until 1 year from signature or until your case is closed, whichever is first.

You also have the right to revoke or alter the consent form at any time. In order to make any changes to consent, you must put them in writing with your signature and effective date.

Please discuss concerns or questions with your therapist pertaining to consent, release of information, and how any changes affect you.

Patient Signature *

Clear Signature

Date *