AUTHORIZATION TO DISCLOSE
PROTECTED HEALTH INFORMATION
This form, when completed and signed by you, authorizes me to release PROTECTED HEALTH INFORMATION from your clinical record to the person whom you designate.
I authorize my psychologist, Floyd Covey, Ph. D., and/or his administrative staff to release the following information: __________________________________________________________________________________________ __________________________________Psychological Information_____________________________________________
The above information is to be released to: ________________________________________________________________________________________________________________
This authorization shall remain in effect for one year from the date of the signature, or until this specific date: ______________________________.
At any time, you have the right to revoke this authorization, only in writing, by sending such a written notification to the following address: Floyd Covey, Ph. D., P.O. Box 69, and Collierville, TN 38027-0069. However, your revocation will not be effective to the extent that Dr. Covey has taken action in reliance upon your authorization, or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule.
Name of Patient: _____________________________________________
Signature of Patient: __________________________________________
Name of Guardian, If Patient is a Minor: __________________________
Relationship of Guardian to Patient: ______________________________
Signature of Guardian: _________________________________________
Date of Signature: ___________________________