Consent For Release of Information Patient Name* First Last PGC Counseling has my permission to exchange the information checked below to/from:Agency / Name: Address: Phone / Fax (if necessary): Purpose of this request for information is: Dates of Service From: MM slash DD slash YYYY To: MM slash DD slash YYYY Items Covered by this release of information: (A separate release is required to release HIV related information)Send: Psychiatric Evaluation Psychological Evaluation Medical History and Physical Treatment Summary Discharge Summary Medication Records Issues Regarding Court / Legal Matters Compliance to Treatment Lab Results Other Receive: Psychiatric Evaluation Psychological Evaluation Medical History and Physical Treatment Summary Discharge Summary Medication Records Issues Regarding Court / Legal Matters Compliance to Treatment Lab Results Other By signing this consent, I am giving the authority to provide information from my confidential case record to the person or agency listed above. I understand that I do not have to provide such consent, and do so freely. I also understand that I can revoke this consent at any time by providing PGC Counseling with my intent to do so. I understand that this consent is valid for one year after the date of my signature unless otherwise indicated below. I understand that the information used or disclosed may not be subject to re-disclosure by the facility receiving it, and would then continue to be protected by federal agency regulations. This Consent is Valid From: MM slash DD slash YYYY Until MM slash DD slash YYYY Parent Guardian SignatureDate MM slash DD slash YYYY Client Signature (if over the age of 14)Date MM slash DD slash YYYY Oral Consent First Last is physically unable to sign this consent. I verify that he/she understands the nature of this release and freely gave his/her consent. Signature of WitnessDate MM slash DD slash YYYY Prohibition of Disclosure: The information has been disclosed to you from whose confidentiality is protected by federal law. Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person whom it pertains or as otherwise permitted by such regulations. A general release of information is NOT sufficient for this purpose.
