Consent To Release Information Form Psychology Template for United States

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Key Requirements PROMPT example:

Consent To Release Information Form Psychology

"I need a Consent To Release Information Form Psychology that allows my practice to share specific therapy session notes with a court-appointed guardian, with the authorization expiring on June 1, 2025, and including special provisions for substance abuse treatment records."

Document background

The Consent To Release Information Form Psychology is essential when psychological records need to be shared between healthcare providers, insurance companies, or other authorized parties. This document became particularly crucial after the implementation of HIPAA in 1996, which established strict guidelines for protecting patient privacy. The form ensures compliance with federal and state regulations while facilitating necessary information sharing for treatment, payment, or other legitimate purposes. It must specify exactly what information can be shared, with whom, for how long, and for what purpose, while maintaining the patient's right to revoke consent.

Suggested Sections

1. Patient Information: Complete identifying information of the patient/client including name, date of birth, address, and contact details

2. Provider Information: Details of the healthcare provider/facility releasing the information, including name, address, license number and contact information

3. Recipient Information: Details of the person/entity authorized to receive the information, including name, organization, address, and relationship to patient

4. Information to be Released: Specific description of what information can be shared, including date ranges and types of records

5. Purpose of Release: Stated reason for the information disclosure and how the information will be used

6. Duration: Time period for which the consent remains valid and expiration date of authorization

7. Rights Statement: Statement of patient's rights regarding the release, including right to revoke and limitations

Optional Sections

1. Substance Use Information: Additional consent section specifically for release of substance use treatment information under 42 CFR Part 2

2. HIV/AIDS Information: Special authorization section for release of HIV/AIDS-related information as required by state laws

3. Electronic Records Transfer: Specific provisions and consent for electronic transfer of records and associated risks

Suggested Schedules

1. State-Specific Addendum: Additional provisions and requirements specific to the applicable state law

2. Notice of Privacy Practices: Detailed explanation of how medical information may be used and disclosed, and how the patient can access their rights under HIPAA

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Education
Social Services
Legal

Relevant Teams

Medical Records
Compliance
Legal
Mental Health Services
Administration

Relevant Roles

Psychologist
Mental Health Counselor
Healthcare Administrator
Privacy Officer
Medical Records Coordinator

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Let's create your Consent To Release Information Form Psychology

Authors

Alex Denne

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