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Counseling and Psychological Services

Authorization

This form when completed and signed by you authorizes Counseling and Psychological
Services (CAPS) to release protected information from your clinical record to the
person/agency you designate.

I, _______________________, authorize ________________________and/or his or
her clinical supervisor at CAPS and/or the Director of CAPS and/or the administrative

staff at CAPS (cross out if not applicable) to release to and/or receive from:________________________________________________________

The following information:

□ All information obtained
□ Attendance at therapy
□ Diagnoses
□ Treatment recommendations
□ Adherence to treatment recommendations
□ Lab results
□ Urine drug screens and other biological markers related to substance use
□ Prognosis

□ Psychological suitability for continuing in academic program
□ Ability to function in class work
□ Ability to function in clinics
□ Recommendations regarding medical leave of absence
□ Letter summarizing my care
□ Results of psychometric testing
□ Other ____________________________
            ____________________________

I am requesting the release of this information for the following reasons:

□ At the request of the individual (all that is required if you do not desire to state a specific purpose)
□ At the request of the program
□ Other ________________________________________________________

This authorization shall remain in effect until (fill in expiration date): ________________

You have the right to revoke this authorization in writing at any time by sending such
written notification to the CAPS office.  However, your revocation will not be effective
to the extent that CAPS has already taken action in reliance on the authorization.

I understand that CAPS generally may not make services conditional upon my signing an
authorization unless the services are provided to me for the purpose of creating health
information for a third party.  (For example, if I am required by my Dean or Program
Director to receive psychological evaluation or treatment.)

I understand that information used or disclosed pursuant to the authorization may be
subject to redisclosure by the recipient of my information and no longer protected by
the HIPAA Privacy Rule.

________________________________
 
 Signature of Patient 

_______________________
  
  Date

(If the authorization is signed by a personal representation of the patient, a description of such representative’s authority to act for the patient must be provided.)

Fax to (843) 792-2535For questions please call, (843) 792-4930.

Reviewed 7/21/2010

 
 
 

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