Joy Meadows Release of Information

This form provides your therapist with written permission to communicate with other individual providers regarding your treatment (e.g. previous treating therapist, current health care providers, therapy mentors, co-treating therapists or providers) to the extent indicated below.

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I am currently under the care of the following healthcare Professional(s) who are using office space at the Joy Meadows location (check all that apply):
I hereby authorize the person/agency (allows information exchange with anyone representing that agency) selected above to use, disclose, request and/or exchange my protected health information as indicated below to (check all that apply):
Information to be released/exchanged (check all that apply):
I hereby authorize the person/agency selected above to use and/or disclose client name and therapy time to Joy Meadows program staff for the purpose of scheduling therapy space at the Joy Meadows facility.
This release will be valid until the termination of treatment or authorization from client to revoke. This authorization may be revoked at any time. I have read the above and authorize the request for disclosure of Protected Health Information. I understand I may revoke this right at any time by providing verbal or written notice to those authorized in this agreement, except to the extent that action has been taken in reliance and on the authorization or as otherwise stated in the provider’s Notice of Privacy Practices.
Clear Signature
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Address