(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**

Printed Name of Client:

Client Date of Birth:

_____________________________________________________________________________________________________

RELEASE OF INFORMATION

I authorize the release of protected health information (PHI) including the diagnosis, medical records, examination results, medication dose changes, and claims information to Quality Telepractice, LLC and its agents for medical treatment or consultation, billing or claims payment, or related services.

I authorize Quality Telepractice, LLC to use, disclose, and release protected health information (PHI) including the diagnosis, medical records, examination results, medication dose changes, and claims information to:

Spouse:
Child(ren):
Other:
OR
Information is not to be released to anyone other than me.
______________________________________________________________________________________________________

MESSAGES
You may call my home phone:
You may call my cell phone:

The best time to reach me is:
Day(s) of Week:

Time of Day:

If unable to reach me:
You may leave a message asking me to return your call.
OR
Do not leave messages on my phone voice mailbox.
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EMAIL MESSAGES
You may email me with detailed information, including attachments of medical records. My email address is:
OR
Do not use my email to leave detailed messages and information.

This Release of Information will remain in effect until terminated by me in writing. I understand that I may revoke this authorization by notifying Quality Telepractice, LLC in writing with the understanding that previously disclosed information would not be subject to my revocation request.
This release specifically excludes any psychiatry and psychology evaluations/records which are further restricted by HIPAA regulations.
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Printed Name of Client or Guardian:

Relationship to Client:

Today's Date:

Signature of Client or Guardian: