Jennifer Danhauser Release of Information

Jennifer Danhauser, LPC

Counseling and Therapy Services

Authorization for Release of Information

Client Name:
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I hereby authorize Jennifer Danhauser, LPC to (check one or both):
Address:
Purpose of Disclosure (Please Check All That Apply):
Information Requested (Please Check All That Apply):
Dates of Information to be Released
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1) My authorization is given voluntarily in writing for the above stated purpose(s) and will remain in effect for ONE YEAR from the date of signature OR through ________________(up to one year).

2) I understand that by not signing this authorization it will not affect my treatment or payment for services provided by Jennifer Danhauser, LPC.

3) I may revoke (stop) this authorization at any time in writing, although it will not change any action taken between the date of original authorization and date the revocation is received by Jennifer Danhauser, LPC.

4) I may inspect or copy information to be used or disclosed pursuant to this authorization, copying fees may apply.

5) I am entitled to receive a copy of this authorization.

6) I understand information released through this authorization might be re-disclosed by the recipient and may no longer be protected by Federal/State privacy regulations.

By typing your name below, you acknowledge having read a copy of Jennifer Danhauser’s Notice of Privacy Practices and Client Rights.
Consent:(Required)
Signature of Client:(Required)
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