AUTHORIZATION TO OBTAIN/RELEASE INFORMATION

    This form when completed and signed by you authorizes Penllyn Counseling Associates LLC to obtain/release protected information from the identified party designated.

    I authorize and give my permission for Penllyn Counseling Associates LLC to obtain/release information personal, medical and or psychotherapy notes.
    Check those that apply:
    PersonalMedicalPsychotherapy

    This authorization shall remain in effect until I am no longer a client of Penllyn Counseling Associates LLC.

    I have the right to revoke this authorization, in writing, at any time by sending such written notification to Penllyn Counseling Associates LLC. However, my revocation will not be effective to the extent that Penllyn Counseling Associates LLC has taken action in reliance on the authorization.

    I understand that my sessions with Penllyn Counseling Associates LLC are not contingent upon my agreement to sign this authorization.

    I understand that information used for Penllyn Counseling Associates LLC to the authorization may be subject to re-disclosure by the recipient of my information and no longer protected by the HIPAA Privacy Act.


    I have been informed that I may revoke this authorization (except to the extent that has been taken in reliance thereon) by written or oral communication to Penllyn Counseling Associates LLC. I understand that this authorization is voluntary. I have also been informed of my right, subject to Section 7100.11.3 of the regulations promulgated under the Mental Health Procedures Act of 1976, to inspect the information to be obtained. Furthermore, I consent to the disclosure of information, if any, relation to my drug or alcohol abuse or dependency provided that disclosure is limited, pursuant to Section 8 of the Pennsylvania Drug and Alcohol Abuse Control Act of 1972, to 1) medical personnel for the purpose of diagnosis and treatment, and 22) government or other officials exclusively for the purpose of obtaining benefits due me as a result of my drug or alcohol abuse or dependency. I certify that this form has been fully explained to me and that I understand it. I know I may have a copy of this authorization.

    Signature of Client


    Electronic Signature: