BlueStone Psychotherapy, PLLC

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:

to release records by means of written or verbal dissemination

to request information

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

verbal or written communication between professionals

dates of treatment attendance

diagnosis

test results

treatment progress

clinical and medical documentation

other (specify)

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 This consent, if not withdrawn, will expire one year from the date of signature.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:

self

Parent/legal guardian

other (describe)

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Your legal name

Your email address

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Signed by BlueStone Psychotherapy, PLLC
Signed On: May 7, 2023

Signature Certificate

Document name: Authorization to Release/Exchange Confidential Information

Unique Document ID: acfef7080c0b01b81aa2fe52f8f2118e98742f07

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March 9, 2023 8:11 am EDT

Authorization to Release/Exchange Confidential Information Uploaded by BlueStone Psychotherapy, PLLC - suzie@bluestonepsychotherapy.com IP 104.139.124.160

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https://bluestonepsychotherapy.com/

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