This form is used to authorize the release of psychotherapy notes in accordance with the Privacy Rule of Health Insurance Portability and Accountability Act of 1996 (HIPPA). HIPPA provides special protections to certain medical records known as “psychotherapy notes”. Psychotherapy notes are defined under HIPPA as notes recorded by a health provider who is a mental health professional “documenting or analyzing the contents of conversation during a private counseling session or group, joint, family counseling session and that are separated from the rest of the individual’s medical record”. Excluded from the definition are the following: Medical prescription and monitoring Counseling session start and stop times The modalities and frequencies of treatment furnished Any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. In order for the medical provider to release psychotherapy notes to an attorney or other third party, the patient who is the subject of the psychotherapy notes must sign a HIPPA-compliant authorization form that specifically allows for the release of the psychotherapy notes. Such authorization must be separate from an authorization to release other medical records; therefore two authorization forms must be signed by the patient in order for the provider to release medical records and psychotherapy notes. Completion of this document authorizes the disclosure and/or use of psychotherapy notes. Failure to provide all information may invalidate this authorization.Name of the Client:(Required) First Name Last Name USE AND DISCLOSURE OF PSYCHOTHERAPY NOTES I hereby authorize: Heather Fairfax, PsyD, LPC, LMFT Transcendent Truth Inc 2601 Wheatland Woods Drive Fredericksburg, Virginia 22406Address(Required) Street Address City State / Province / Region ZIP / Postal Code To release psychotherapy notes concerning me to the following recipient:(Required) (Person/Organization) Address(Required) Street Address City State / Province / Region ZIP / Postal Code (Required) Client requests records to be faxed to another agency/therapist’s office. Client is aware of the confidentiality risks involved and releases Transcendent Truth Inc. from responsibility for this FAX.Fax Number The following is to be released:(Required) Psychotherapy notes Date(s) of service:(Required) MM slash DD slash YYYY PURPOSEThe purpose for the release of this information is:(Required) Continuity of care* Pending legal action (attorney) At the request of the client Other: (Specify) *If, for continuity of care, records needed for appointment on(Required) MM slash DD slash YYYY (date) At(Required) Hours : Minutes AM PM AM/PM (time) Entity/Provider Authorized to Make the Disclosure: Transcendent Truth Inc.Person(s) Authorized to Receive the Disclosure:(Required) This Authorization will expire on(Required) MM slash DD slash YYYY or upon the happening of the following event:(Required) RESTRICTIONS: I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing substance abuse information under Federal Substance Abuse Confidentiality Requirements. I realize that the office and its staff have a responsibility to maintain the confidentiality of the medical records in its possession. I understand that once the information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. The office will not be held responsible for any subsequent disclosure by the recipient of the mental health information. I release Transcendent Truth Inc. and staff of any liability that may arise as a result of any subsequent disclosure of my mental health information by the recipient. MY RIGHTS I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits. I may inspect a copy or obtain a copy of the mental health information that I am being asked to allow the use or disclosure of. I may revoke this authorization at anytime, but I must do so in writing and submit it to the following address: Transcendent Truth Inc 2601 Wheatland Woods Drive Fredericksburg, VA 22408 My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization. I have a right to receive a copy of this authorization. Authorization and Signature: I authorize the release of my confidential protected health information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.Signature of the Client:(Required)Client Name(Required) Signature of Personal Representative:(Required)Personal Representative Name(Required) Relationship to Client if Personal Representative:(Required) Date:(Required) MM slash DD slash YYYY Δ
