Authorization for Release of Health Information

I, _______________________________________________________________hereby authorize [  ]Darwin Kellicut MSW, LCSW, or [   ] Raquel Kellicut, MA, LCPC of  Poignant Possibilities, LLC,  to disclose my/_____________ health information as  described in this authorization.

[1]      Specific person(s) or organization(s) to whom Poignant Possibilities, LLC, is authorized to:

______Release information to   ______obtain information from   _____mutally exchange information  with:

Name of organization:____________________________________________________________________

Person (Name and Title):_____________________________________Phone:_______________

Address:__________________________________________________Fax:_________________

City:___________________________  State:______Zip:__________
OK to Fax__________(initial)

[2]      Specific description of the information to be disclosed by Poignant  Possibilities, LLC (intial all that apply):
 
_____Complete copy of my records   _____Evaluation 	             _____Psychiatric history

_____Progress notes		        _____Medication record	_____Medical information

             _____Psychological testing 	        _____School records	_____Treatment information

_____Substance abuse		          _____HIV information
	
_____Treatment/Diagnosis of Sexually transmitted diseases

_____Billing dates of service, diagnosis and insurance coverage

_____Other:_________________________________________________________________

[3]    Right to Revoke: I understand that I have the right to revoke this authorization at any time by notifying Poignant Possibilities, LLC, in writing at 1420 Lincoln Way, Suite 500, Coeur d’Alene, Idaho 83814. I understand the revocation is only effective after it is received by Poignant Possibilities, LLC. I understand that any use or disclosure made prior to the revocation of this authorization will not be affected by the revocation.
[4]    Potential for Re-disclosure: I understand that after this information is disclosed, federal law might not protect it, and the recipient might re-disclose it.
[5]    Right to Copy: I understand that I am entitled to receive a copy of this authorization.
[6]    Expiration of Authorization: This authorization will expire [choose and complete one]:

___   On  the _______ day of _____________________________, 20_____.
                                     (We suggest one year from today’s date.)

                            ___   Upon the occurrence of the following event:_________________________

                                     _______________________________________________________________