Co-Parenting Solutions, LLC

7. Authorization to Release or Exchange Information


Client Name:
Maiden / Other Name:
Client Address:  
Phone Number:  

Minor Name(s) and DOB (if also applicable):
 

I, , hereby authorize Co-Parenting Solutions, LLC and Jordana Wolfson, LMSW, MA, ED SP to release information contained in my treatment record (including, if applicable, mental health services, information about substance abuse treatment, and information about HIV infection or AIDS). If you are court-ordered, be sure to include who you are working with through the court.  If you don't know their name, just give their title, such as Judge or FOC, and whatever county you are working with.

Name(s) to Whom Information may be Released By Jordana Wolfson, LMSW, MA, ED SP, of Co-Parenting Solutions, LLC:

Name(s) of Person / Agency: Email:  Phone Number:   

Name(s) of Person / Agency #2: Email: Phone Number:   

Name(s) of Person / Agency #3: Email: Phone Number:   

Dates of Services to be Released: This authorization is in effect for up to 5 years from date of signature unless you rescind same in writing to Jordana Wolfson, 31000 Telegraph Road, Suite 280, Bingham Farms, MI 48025.

Description of Information to be Released:  

The Purpose and Need for Disclosure of Information:  

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to CoParenting Solutions. We may have already released the information based on your original authorization. We will not release any additional information after we receive your revocation. We will not condition treatment or payment based on this authorization or revocation of authorization unless otherwise allowed by law.

Your protected health information will be disclosed as specified in this authorization. This authorization will expire one (1) year from the date of signature, or until we have completed the disclosure(s) you have requested, whichever is longer. This information could be subject to re-disclosure by the recipient and may then no longer be protected.

A copy of this form is as valid as the original.

Signed by:

 

Date Signed:

Revised 12/2019

Leave this empty:

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Signature Certificate
Document name: 7. Authorization to Release or Exchange Information
lock iconUnique Document ID: e9866988b1de1082900652930673a6c9db4c93a0
Timestamp Audit
July 24, 2020 12:32 pm EDT7. Authorization to Release or Exchange Information Uploaded by Jordana Wolfson - jordana@coparentingsolutionsllc.com IP 65.132.18.5
August 18, 2020 10:08 am EDT Document owner michael@yourppl.com has handed over this document to jordana@coparentingsolutionsllc.com 2020-08-18 10:08:41 - 75.128.132.184