Information Release | Northern Ohio Health and Wellness

I hereby authorize Northern Ohio Health and Wellness (“Provider”) to disclose to (name and/or function of the person or entity to whom disclosure is to be made)*

Please enter the name of the person, persons, doctor, group, etc... who will receive your information. This is the "Recipient."

the following protected health information for*

Please enter your name or the client's name and date of birth.

Name of Your Therapist

Please enter the name of your therapist at Northern Ohio Health and Wellness.

What information are you authorizing the release of?*

If you checked "Other" please explain.

I understand that I have a right to receive a copy of this authorization, and that any cancellation or modification of it must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider has taken action in reliance upon it. I also understand that such revocation must be in writing and received by Provider to be effective. I authorize the disclosure of the health information described above for the following purpose:

The specific uses and limitations on the uses of my health information by Recipient are as follows:

I understand that Provider cannot condition treatment upon me signing this authorization. I understand that the health information disclosed pursuant to this authorization may be subject to re-disclosure by Recipient and that the Federal Privacy Rule may no longer protect such information, although the re-disclosure of such information may be protected by applicable Ohio law. Provider is authorized to disclose the protected health information specifically listed above until:

Authorization Expiration Date (If no authorization expiration date is entered then this agreement will continue indefinitely).

Filled out by (Client or Client's Representative):*

First Last

Date*

If signed by other than client, please indicate the relationship between catient and his/her Representative:

By clicking you are submitting your signature with the above document and agree to all of the above.

Agree

Authorization Form

Authorization Form