If the client is 12 or older, they must sign for themselves.
If there is another responsible party, they will need to fill out this form separately.
1.Right to Revoke: I understand that I have the right to revoke the authorization in writing at any time subject to the exceptions stated below. To revoke this authorization, I understand that I must make my request in writing and clearly state that I am revoking this specific authorization. In addition, I must sign my request and then mail or deliver my request to Lighthouse Christian Counseling, 5236 Strauss Cabin Road, Fort Collins, CO 80528.
2. Exceptions to Right to Revoke: I understand that my written request to revoke this authorization will not affect the ability of Lighthouse Christian Counseling to continue to use or disclose my information to the extent that it has already been acted in reliance on this authorization.
3. Payment: According to Colorado State Statutes, Lighthouse Christian Counseling may charge reasonable fees for copies of medical records. Alternatively, we may provide you with a summary or explanation of your information if you agree to that, and to its cost, in advance. If you indicate above that you would like a summary of your information, we will inform you of the cost for that summary prior to providing you with the summary. If you do not agree to the charge, we will not prepare the summary.
4. Potential for Re-disclosure: Your information, once disclosed according to this authorization, will no longer be protected by the federal privacy law (known as “HIPAA") and the recipient of the information may potentially re-disclose it.
5. Prohibition on Re-disclosure of Drug/Alcohol Information: The information that will be disclosed may contain records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit the receiving party from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.
6. Prohibition on conditioning of authorization: We are prohibited from conditioning treatment on your signing this authorization unless; you are receiving research-related treatment; or the only reason Lighthouse Christian Counseling is providing you with mental health care is to make a report to a third party, such as your employer (e.g., fitness to return to work) or school.
7. This authorization is binding: The statements made in this authorization are binding, controlling and I understand that they take precedence over statements made in the Lighthouse Christian Counseling Mandatory Disclosure Statement. Authorization must be signed by the client or by parent/legal guardian of a minor, or by the legal representative when the client lacks the decisional capacity, or if the client is physically unable to sign but mentally understands and consents.
This release is in effect until termination of services.
You do have the right to revoke this Release of Information at any point in time in writing.
Email email@example.com to revoke this Release.
If you do not have a driver's license and are over 15, please type ? and contact your counselor for more instruction.