Records Request Form

Client Legal Name _______________________________________

I authorize:

Catherine M. Klingler MS, LPC, LCDC, C-DBT, CCTP-II, CF-CBT

The following information: ______________________________________________________________________________________________

To be provided to or released from:

Provider Name_________________________________

Phone #____________________________

Your relationship to client: ________________________

The above information will be used for the following purposes (Initals):

I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. _________

I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules._________

I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed of what information will be given, its purpose, and who will receive the information. _______

I understand that I have a right to receive a copy of this authorization. _________

I understand that I have a right to refuse to sign this authorization. __________

If you are the legal guardian or representative appointed by the court for the client, please attach/provide a copy of that documentation to this authorization to receive this protected health information.

_______________________________________

Signature

__________________________________

Date

_______________________________________

Witness Name Printed (if client is unable to sign or a minor)

______________________________________

Witness Signature (if client is unable to sign)

_________________________________

Witness Date