Disclosure Of Protected Health Information Authorization Form


    AUTHORIZES:
    Brill Counseling
    4433 N. Oakland Ave.
    Shorewood, WI 53211

    Release Of Protected Health Information To:

    In Compliance With Wisconsin Statutes Which Require Special Permission To Release Otherwise Privileged Information, Please Release Records Pertaining To:

    This Disclosure Is Being Made for the Following Purpose(s):

    Changing TherapistFurther Medical CareWork CompPersonal UseUse Attorney/Court CaseCollateral Contact

    I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans or health care clearinghouses, who must follow the federal privacy standards, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information may be redisclosed without obtaining my authorization.

    YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

    RIGHT TO INSPECT OR COPY THE HEALTH INFORMATION TO BE USED OR DISCLOSED – I understand that I have the right to inspect or copy the health information I have authorized to be used on disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contracting the Health Information Services Dept. RIGHT TO RECEIVE COPY OF THIS AUTHORIZATION – I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form. RIGHT TO REFUSE TO SIGN THIS AUTHORIZATION – I understand I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization. RIGHT TO WITHDRAW THIS AUTHORIZATION – I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawal, I may contact the Health Information Services Dept. I am aware that my withdrawal will not be effective as to uses and/or disclosures of my health information that the person(s) and/or organization(s) listed above have already made in reference to this authorization.

    EXPIRATION DATE: This authorization is good until the following date(s) or for one year from the date signed.

    I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.

    Signature