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Patient Authorization for Release of Health Information

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Blue Moon Senior Counseling will not release confidential information, in person or by telephone, email or fax to any unauthorized people. When returning phone calls, we will not leave a message on an answering machine or voicemail without written consent. Information may not be given to an unauthorized person who may answer your phone. If you would like to authorize us to release medical information to someone other than yourself or to leave information on a recording device, please specify below. I understand and authorize Blue Moon Senior Counseling and any of its affiliates/subsidiaries to release confidential health information pertaining to my care by the following methods and to the following people. I understand that it is my responsibility to notify Blue Moon Senior Counseling if the authorization information changes.

I consent to Blue Moon Senior Counseling and any of it's affiliates/subsidiaries being able to leave messages for me on my:

I consent to Blue Moon Senior Counseling and any of it's affiliates/subsidiaries to share confidential information regarding my care to:

Name / Entity	Relationship	Phone / Fax

I authorize this information to be disclosed in the following ways:

Written/photocopy/paper

Verbal

Fax

Specific description of the Protected Health Information that I authorize for disclosure:

Progress Notes

Entire Health Record (Including but not limited to information regarding medical/health treatment, insurance, demographics, referral documents, etc)

Treatment Progress

I give specific authorization for the following to request disclosures of my health information:

At the request of the individual (patient)

At the request of Other: (List names/Relationships)

This authorization is valid, unless a specific expiration date or event is specified here:

I understand I may revoke this authorization at any time in writing. I am entitled to make a copy of, or request to receive a copy of this authorization. I acknowledge by my signature below that I have read and understand this authorization, it accurately reflects my wishes, and a photocopy, facsimile, or other electronic copy is as valid as the signed original.

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Your legal name

Your email address

Please Confirm full name and signature.

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June 3, 2020 4:37 pm PST

Patient Authorization for Release of Health Information Uploaded by Melanie Donohue - new@bluemoonseniorcounseling.com IP 172.250.158.178