Power Counseling & Treatment Services, LLC
-Helping clients discover inner healing powers.
Azubike Aliche, M.Sc., MSW, PMC. (CFT), LCSW.
Authorization Form
I, ______, whose Date of Birth is ______,
Name of Patient
authorizePower Counseling and Treatment Services, LLC to disclose to and/or obtain from:
______the following information:
Name of person or organization, phone #, fax# and address
Description of Information to be Disclosed:
Patient should initial each item to be disclosed.
____ Presence/ Participation in Treatment ____ Discharge/Transfer Summary
____ Dates of Treatment ____ Continuing Care Plan
____ Psychosocial Evaluation ____ Psychological Evaluation
____ Diagnosis ____ Psychiatric Evaluation
____ Treatment Plan or Summary ____ Medication Management Information
____ Current Treatment Update ____ Nursing/Medical Information
____ Progress in Treatment ____ Toxicological Reports/Drug Screens
____ HIV/AIDS Related Information
____ All Progress Notes (including any drug/alcohol information)
____ All Progress Notes (excluding any drug/alcohol information)
____ Other ______
____ Other ______
Purpose
The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment, and, when appropriate, coordinate treatment services.
If other purpose, please specify: ______
Revocation
I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Power Counseling and Treatment Services, LLC atPO Box 146, Millville, NJ 08332. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
Expiration
Unless sooner revoked, this consent expires on the followingdate:______or as otherwise indicated:______.
If a calendar date is not stated, information may only be released on the date the authorization is received.
Conditions
I further understand that Power Counseling and Treatment Services, LLC will not condition my treatment upon whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:______
Form of Disclosure
Unless you have specifically requested in writing that the disclosure be made in a certain format, I reserve the right to disclose information as permitted by this authorization in any manner that I deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format, or electronically.
I understand that I have the right to inspect and copy the information to be disclosed. I will be given a copy of this authorization for my records.
Signature of Patient Date
Signature of Parent, Guardian or Personal Representative*
*If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (e.g., power of attorney, healthcare surrogate, etc.)
____ Check here if patient refuses to sign authorization
______
Signature of Social Worker Attesting to Identity & Authority Date
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