My Tribe Authorization to Release and Receive Protected Health Information (PHI) Client Name * First Name Last Name Client Date of Birth MM DD YYYY Name of Person(s), Physician, or Agency to release and receive information with My Tribe Counseling: Agency Name Agency Address Address 1 Address 2 City State/Province Zip/Postal Code Country Agency Phone Number (###) ### #### Agency Fax Number (###) ### #### Email * I authorize release of (check all that apply) Mental health records (including intake documents) Summary of Progress Notes Educational Records Psychiatric Evals/CBHA Physical/Health records Other I hereby request and authorize My Tribe Counseling to release/receive written or verbal information on a need-to-know basis for coordination of care, disability applications, or court hearings with the above party. Confidentiality of specific session information is protected except in specific situations that require, by law, notification of other agencies (ie: abuse). I understand that this form may be used to release information related to mental health treatment, including assessments and lab reports. Any release of substance abuse information must be pursuant to 42 CFR. There are other special restrictions which apply to the release of information regarding HIV, abuse reports, etc. I understand that I have the right to refuse to sign this Authorization or to rescind my consent in writing at any time prior to the release of the information. This authorization expires 1 (one) year from date signed unless other written instructions are received. Client Signature Date Signed MM DD YYYY Guardian Signature Date Signed MM DD YYYY Thank you!
