Cathy Weeg, LPC

Counseling and Therapy Services

Authorization for Release of Information

Client Name:

First Last

Date of Birth:

Social Security Number:

I hereby authorize Cathy Weeg, LPC to:

Release Information to:

Obtain Information from:

Person/Agency:

Address:

Street Address: City: State: Zip:

Phone:

Fax:

Purpose of Disclosure (please check)

Treatment Planning

Continued Treatment

Coordinate Treatment

Personal Use

Legal Use

Employment/Benefit Assistance

Billing/Insurance

Other

If 'Other', please specify

Information Requested

Verbal Information

Medical Record

Medical: H&P, D/C Summary, Labs

Psychiatric: H&P, Labs, Evaluations D/C Summary

Outpatient Records

Diagnosis/Reports/Treatment Notes/Labs

Psychiatric Evaluations/Dr. Notes

Intake/Case Notes

Treatment Plans/Reviews

Psychological Assessments

Termination Summary

Other

If 'Other', please specify

Dates of Information to be Released

From:

To:

Must Initial for Disclosure of:

Psychological Information (i.e. diagnosis, case notes, intake, treatment plans, termination summary)

Alcohol and Drug Information/ Treatment

1)My authorization is given voluntarily in writing for the above stated purpose(s) and will remain in effect for ONE YEAR from the date of signature OR through ________________(up to one year). 2) I understand that by not signing this authorization it will not affect my treatment or payment for services provided by Cathy Weeg, LPC. 3) I may revoke (stop) this authorization at any time in writing, although it will not change any action taken between the date of original authorization and date the revocation is received by Cathy Weeg, LPC. 4) I may inspect or copy information to be used or disclosed pursuant to this authorization, copying fees may apply. 5) I am entitled to receive a copy of this authorization 6) I understand information released through this authorization might be re-disclosed by the recipient and may no longer be protected by Federal/State privacy regulations.

By typing your name below, you acknowledge having read a copy of Cathy Weeg’s Notice of Privacy Practices and Client Rights.

Consent:(Required)

I authorize the above for the stated purposes.

Signature of Client:(Required)

First Last

Date:(Required)

Counseling and Therapy Services

Cathy Weeg Release of Information

Cathy Weeg, LPC

Counseling and Therapy Services

Authorization for Release of Information

By typing your name below, you acknowledge having read a copy of Cathy Weeg’s Notice of Privacy Practices and Client Rights.

Counseling and Therapy Services