BlueStone Psychotherapy

Authorization to Release/Exchange Confidential Information


I, , hereby authorize:

 

 BlueStone Psychotherapy, PLLC,  17714 Kings Point Dr, Suite B, Cornelius, NC 

 

To communicate with or release information to:

 

In the following manner:

 

The information to be used will be limited to the following (check any that apply):

 

I understand that the medical or mental health record to be released may contain information pertaining to psychiatric and/or substance abuse diagnosis and treatment, and may also contain confidential HIV (AIDS) – related information. I understand that the information released by this consent shall not be further released in any way to any other person, entity, or others without additional written consent from me. I understand that I may withdraw this consent at any time prior to the release of the above information. I understand that if I am signing as the parent of a minor or as a guardian, the records release may contain references to myself and my family. I understand that I may revoke this consent to release information at any time prior to the stated expiration. I also understand that any release made between the time I authorized it and then revoked it shall not constitute a breach of my right to confidentiality. This consent, if not withdrawn, will expire one year from the date of signature.

 

PLEASE NOTE:  You must complete and sign the section below even if you are not authorizing communication/release of information.

Your relationship to client:

Leave this empty:

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Signature Certificate
Document name: Authorization to Release/Exchange Confidential Information
lock iconUnique Document ID: 984e0ebfa625b9045eb36aaf3724732020aa36b2
Timestamp Audit
March 9, 2023 8:11 am EDTAuthorization to Release/Exchange Confidential Information Uploaded by BlueStone Psychotherapy, PLLC - office@bluestonepsychotherapy.com IP 104.139.124.160