Elizabeth Polasek, M.A., L.M.H.C.
360-633-3253-Phone
360-730-2019-Fax
www.elizabethpolasek.com
Office Address: 765 Wonn Rd. #C202, Greenbank, WA  78253

RELEASE OF PROTECTED HEALTH INFORMATION -
AUTHORIZATION FORM

Name of Patient ___________________________ Birthdate: ____________

I authorize release of confidential information from: ____________________________ 

to: _____________________________  for the purpose of treatment planning.

Which can include diagnoses, history of patient, medications and clinical impressions.

This authorization shall remain in effect until (check one):
Treatment has been terminated ___ or one year from this date:   Date : ______________
 
After this expiration information can no longer be used or disclose my protected health information without first
obtaining a new authorization form.  I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification. I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of the information and no longer protected by the HIPAA Privacy Rule.

__________________________________
Signature of Patient or Personal Representative Printed Name

___________________________________________________ _________________
Personal Representatives authority (e.g. “Parent” or “Guardian”) Date