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Permission to Exchange Information
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Client Name
*
First
Last
My therapist is:
*
John-Mike Nelson, LPC
Joseph Wall, LPC
Kate Lewis, LCSW
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:
*
All
Discharge Summary
Psychological or Forensic Evaluations
Billing
Treatment summary
Urinalysis/Laboratory Results
Other
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
*
Submit
