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Hall & Associates
RELEASE FOR EXCHANGE OF INFORMATION
This authorizes the following person or organization to release the following information to Hall & Associates and Hall & Associates to release to the following person or organization the following information:
Name of Person or Organization
The information to be The information to be released by Hall &
Associates: released to Hall & Associates:
_____ Diagnosis _____ Diagnosis
_____ History _____ History
_____ Summary of Treatment _____ Summary of Treatment
_____ Medications _____ Medications
_____ Lab work _____ Lab work
_____ Psychological Testing _____ Psychological Testing
_____ Alcohol/Drug Evaluation _____ Alcohol/Drug Evaluation
_____ Substance Abuse Treatment _____ Substance Abuse Treatment
_____ HIV/AIDS Status(other communicable disease) _____ HIV/AIDS Status(other communicable disease)
_____ Treatment Plan _____ other (specify)And is to be released for the purpose of communication - written/oral including copies of records. Except for purposes of collection of revenues for professional services rendered, this consent to release is valid for one (1) year or until otherwise specified and thereafter is invalid._________________________________________(Specify date, event or condition that permit will expire)
You are advised that at any time between the time of signing and the expiration date listed above, you have the right to revoke this consent, by making this request verbally and/or to write your request to Hall & Assoc. I understand that said information disclosed may contain psychiatric (K.S.A. 59-2946), substance abuse (42
C.F.R. Part 2) and/or HIV/AIDS (or other communicable disease K.S.A. 65-6001, -6004, -6008, -6009, -6016 and 60427) information. I understand that my records are protected under the Federal and State confidentiality regulations and cannot be released without my written consent unless otherwise provided for in said regulations.
Patients name (maiden or former) Date of Birth
Witness /Position Date Client/Patient age 18 or older Date
Signature of Responsible Party if client is under age of 18 (relationship) Date
______________________________________Patient's or Authorized Person's Signature for Authorization of Payment (I authorized the payment of medical benefits to the physician or supplier for the services described on the attached claim.)
Please send information to the following address: Hall & Associates
1715 E Cedar suite 115
Olathe KS 66062