WHITNEY CAIN, PHD

Release of Information

AUTHORIZATION REGARDING RELEASE OF ADULT CLIENT INFORMATION

bloomsbury therapy

16 n. boylan avenue * raleigh, nc 27603

info@bloomsburytherapy.com * 919.916.5554

Client Information

Name (Last, First, Middle Initial):  _______________________________________________________

Address:  __________________________________________________________________________

Phone(s):  ___________________________________E-Mail:  _______________________________

Release

I, _______________________, hereby authorize Whitney Cain and Bloomsbury Therapy to

____ Exchange Protected Healthcare Information with _______________________________

____ Release Protected Healthcare Information to ___________________________________

____ Request Protected Healthcare Information from ________________________________

______________________________________ Name of Professional & Agency

______________________________________ Agency Address/ Telephone Number

about myself and/or my professional treatment, diagnosis or assessment.

Information to Be Released

__Entire Mental Health Record

__Records pertaining to _________________

__Records dated_______________________

__ Other____________________________

Purpose of Release

___ Mental Health Care

___ Legal Investigation

___ Request of Individual

 ___ Insurance Application/Claim

___ Rehabilitation/Evaluation

___ Other  ______________________

I may revoke this authorization at any time by sending written notification to Bloomsbury Therapy (return receipt requested). I understand that if I do so, information disclosed prior to the written notice cannot be recalled. This authorization may be subject to re-disclosure by the recipient of this request and may no longer be protected by the HIPAA Privacy Rule. This authorization is valid for one year from the date signed.

Signature ________________________________     Date __________________________