Release of Information

Release of Information

Request/Authorization to Release

Protected Health Information

First Name

Last Name

I, the above named counselee, authorize Lamp and Light Ministries LLC to release information from my records in written or verbal form to (note names of authorized pastors/counselors):

Email of authorized individual

Phone number of authorized individual

Information may be released for the following purposes: Required

Reporting progress in counseling

Coordinating care

At the request of the named individual

For the period of time beginning:

For the period of time ending:

HIV-related information and drug and alcohol information contained in these records will be released under this consent unless indicated here:

Do not release

I have had explained to me and fully understand this request/ authorization to release records and information, including the nature of the records, their contents, and the consequences and implications of their release. This request is entirely voluntary on my part. I understand that I may revoke this request at any time. This consent will expire at the earlier of the counselee's request or termination of the formal counseling relationship. I also understand that, if the person(s) or organization(s) that I authorize to receive my protected health information are not subject to federal and state health information privacy laws, subsequent disclosure by such person(s) or organization(s) may not be protected by those laws.

Signature

Printed Name:

Date:

Thanks for submitting!