Before filling out your HIPAA Consent Form, please review these important details to ensure it is completed correctly and processed without delays.

✔ What This Form Does:

• Allows Love Light Mental Health Counseling Services, PLLC to share your health information with a person or organization you authorize.

• Protects your privacy by ensuring only approved parties can access your records.

⚠ Common Mistakes to Avoid:
❌ Forgetting to sign the form (it won’t be processed).
❌ Leaving required sections blank (can cause delays).
❌ Selecting “Other” without explaining why.

💡 Once you’ve reviewed this information, continue to Step 1 below.

📌 Section 1: Patient Information

📝 What This Section Covers:

In this step, you will provide your personal details to ensure the form is linked to the correct health records.

📂 What to Enter in This Section:

✔ Full Legal Name (as it appears on medical records)
✔ Date of Birth (MM/DD/YYYY format)
✔ Social Security Number (optional, but may help with identification)
✔ Full Mailing Address (including street, city, state, and ZIP code)

⚠ Common Mistakes to Avoid:

❌ Using a nickname instead of your legal name.
❌ Entering an incorrect or incomplete date of birth.
❌ Leaving the address blank or using an old address.

💡 Tip: Double-check your information before moving to the next step to avoid delays in processing. See below.

📌 Section 7: Who Will Release Your Information

📝 What This Section Covers:
In this step, you will enter the name of the healthcare provider or entity that is authorized to release your health records.

📂 What to Enter in This Section:

✔ Write: Love Light Mental Health Counseling Services, PLLC
✔ Do NOT enter: The name of an individual therapist.

⚠ Common Mistakes to Avoid:

❌ Leaving this section blank (the request cannot be processed).
❌ Writing a specific therapist’s name instead of the practice name (may cause delays).
❌ Using an incorrect or unofficial provider name.

💡 Tip: Always enter the full practice name to avoid issues with your request. See below.

📌 Section 8: Who Will Receive Your Information

📝 What This Section Covers:
In this step, you will enter the name and address of the person or organization that will receive your health records.

📂 What to Enter in This Section:

✔ Full legal name and mailing address of the recipient.
✔ This could be an attorney, government agency, employer, insurance company, or another healthcare provider.
✔ Double-check the recipient's details to avoid delays.

⚠ Common Mistakes to Avoid:

❌ Leaving this section blank (your request will not be processed).
❌ Writing only a first name or just a general company name (must include full details).
❌ Using an incorrect or outdated address.

💡 Tip: If you’re unsure about the recipient’s details, confirm with them before submitting the form. See below.

📌 Section 9(a): What Information Will Be Released

📝 What This Section Covers:
In this step, you will select which parts of your medical record you want to be released.

📂 What to Enter in This Section:

✔ Medical Record from (date) to (date) → Specify a time range (e.g., 01/01/2023 – Present).
✔ Entire Medical Record → This includes everything except psychotherapy notes.
✔ Other → If you only need specific records, describe what should be released, such as:

• "Billing records from 2023"

• "Progress notes only"

• "Diagnosis and treatment plan"

💡 Tip: If you are unsure what to select, ask your therapist before completing this section.

⚠ Common Mistakes to Avoid:

❌ Leaving this blank (your request cannot be processed).
❌ Selecting “Other” but not specifying what records to release.
❌ Choosing “Entire Medical Record” without understanding what’s included.

💡 Tip: If you need records for legal, insurance, or employment purposes, confirm with the recipient which records are required. See below.

📌 Section 9(b): Authorization to Discuss Health Information

📝 What This Section Covers:
In this step, you can authorize your therapist or healthcare provider to speak about your health information with the recipient listed in Step 3.

📂 What to Enter in This Section:

✔ We recommend that you fill this out to prevent delays in case additional clarification is needed.
✔ Initial the box to give permission.
✔ Enter the provider’s name → Love Light Mental Health Counseling Services, PLLC.
✔ Enter the recipient’s name (same as Step 3).

💡 Tip: If you do not complete this section, the recipient will receive your records but your therapist will not be able to discuss them with them, which may cause processing issues.

⚠ Common Mistakes to Avoid:

❌ Forgetting to initial the box (without initials, verbal discussion is NOT allowed).
❌ Entering the wrong provider name (use Love Light Mental Health Counseling Services, PLLC instead of a specific therapist).
❌ Listing a different recipient than Step 3 (this must match exactly).

💡 Tip: Completing this section ensures that your therapist can provide necessary context about your records if requested by the recipient. See below.

📌 Section 10 & 11: Reason for Release & Expiration of Authorization

📝 What This Section Covers:
In this step, you will indicate why you are requesting the release of your health records and specify when your authorization should expire.

📂 What to Enter in This Section:

✔ Reason for Release (Section 10)

• Select "At request of individual" → This is the most common option and allows flexibility.

• If selecting “Other,” provide a brief explanation, such as:

  • "For disability benefits application"

  • "For legal case regarding custody"

  • "For workplace accommodations"

✔ Expiration of Authorization (Section 11)

• Enter a specific expiration date (e.g., February 6, 2026).

• OR enter an event-based expiration, such as:

  • "At the conclusion of my legal case"

  • "One year from today’s date" (We recommend entering a date that is one year from the date you sign this form.)

💡 Tip: If you’re unsure, we recommend selecting "At request of individual" for the reason and entering an expiration date one year from the date of signing.

⚠ Common Mistakes to Avoid:

❌ Leaving the reason blank (may cause processing delays).
❌ Selecting “Other” without explaining why.
❌ Leaving the expiration blank (this may lead to rejection).
❌ Writing "forever" (HIPAA does not allow indefinite authorizations).

💡 Tip: If the recipient of your records requires a specific reason or expiration date, confirm with them before completing this section. See below.

📌 Section 12 & 13: Signature & Legal Authority

📝 What This Section Covers:
In this section, you will sign the form to authorize the release of your health records. If someone else is signing on your behalf, they must indicate their legal authority to do so.

📂 What to Enter in This Section:

✔ If you are signing for yourself:

• Sign and date the form at the bottom.

• Leave Section 13 blank.

✔ If someone else is signing on your behalf:

• They must print their name in Section 12.

• They must enter their legal authority in Section 13 (e.g., "Parent of Minor Child," "Legal Guardian," "Power of Attorney for Healthcare").

💡 Tip: If someone else is signing, they may need to provide legal documentation proving their authority.

⚠ Common Mistakes to Avoid:

❌ Forgetting to sign the form (it will not be processed).
❌ A non-authorized person signing without legal documentation.
❌ Writing a vague term in Section 13 (must specify legal authority, e.g., "Guardian" instead of just "Family Member").

💡 Tip: If you are unsure whether someone has the legal authority to sign for you, check with your provider before submitting the form. See below.

📌 Final Section: Signature

📝 What This Section Covers:
In this section, you will officially authorize the release of your health records by signing and dating the form.

📂 What to Enter in This Section:

✔ Sign your full legal name in the signature box.
✔ Enter today’s date next to your signature.
✔ If someone else is signing on your behalf, ensure they have completed Sections 12 & 13 and included their legal authority.

💡 Tip: Once signed, this form is legally binding and allows the release of your health records as specified.

⚠ Common Mistakes to Avoid:

❌ Forgetting to sign and date the form (it cannot be processed without this).
❌ Submitting the form without verifying all sections are correctly filled out.

💡 Tip: Before submitting, review the form to ensure all required sections are completed. See below.