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PROTECTED HEALTH INFORMATION

Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Patient: Date Of Birth:

I authorize the use and disclosure of protected health information as described below; and,

Authorize and request Paraclete Ministry Group LLC, dba MyCounselor

TO RELEASE AND/OR MUTUALLY SHARE THE FOLLOWING INFORMATION: any and all billing records; medical records charts; medical reports; chart notes; clinical notes; x-rays and/or radiographic studies and reports of the same; reports of consultation; patient histories/patient questionnaires; reports and records of laboratory testing and other testing; any and all correspondence (in any format) and any other records and documents contained in my file; or, if applicable, for each admission, whether In-Patient, Out-patient, or Emergency Room, the entire record for each admission, to include admitting history & physical; discharge summary; reports of consultation; reports and records of laboratory testing and other testing; reports of consultation; x-rays and radiographic studies and reports of the same; and other records and documents for each admission;

Covering all past, present, and future periods of health care.

The requested information is to be released by/to and/or mutually shared with:

The requested information is to be used or disclosed for the purpose of providing better service to said patient

This authorization shall be in force and effect and not expire until I exercise my right of revocation, as described below,

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so by communicating in writing, with specific reference to this authorization, to the health care provider named in paragraph 2, above, and to MyCounselor. I understand that the revocation will not apply to information that has already been released in response to this authorization.

I understand that I may refuse to sign this authorization. I further understand that the health care provider named in paragraph 2 may not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this authorization.

I understand that after information is disclosed pursuant to this authorization, it is possible that the information may be redisclosed by the recipient and would no longer be protected by applicable medical privacy laws.

I understand that the information in the requested health record may include information relating to Hepatitis B or C, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), and/or human immunodeficiency virus (HIV). It may also contain information about behavioral or mental health services, psychiatric and/or psychological evaluation testing and/or treatment, and treatment for alcohol and drug abuse.

I understand that any information disclosed pertaining to alcohol/drug abuse is protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit the recipient of such information from making any further disclosure unless further disclosure is expressly permitted by my written consent or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of such information to criminally investigate or prosecute any alcohol or drug abuse patient.

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Timestamp

Audit

June 29, 2017 9:56 am MDT

ATD (AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION) Uploaded by MyCounselor Receptionist - forms@mycounselor.online IP 70.174.52.34

April 28, 2022 2:39 pm MDT

MCO Forms - forms@mycounselor.online added by MyCounselor Receptionist - forms@mycounselor.online as a CC'd Recipient Ip: 75.57.19.25

November 1, 2023 12:15 pm MDT

MCO Forms - forms@mycounselor.online added by MyCounselor Receptionist - forms@mycounselor.online as a CC'd Recipient Ip: 184.167.114.171

December 13, 2023 2:27 pm MDT

MCO Forms - forms@mycounselor.online added by MyCounselor Receptionist - forms@mycounselor.online as a CC'd Recipient Ip: 70.174.52.34

December 13, 2023 2:28 pm MDT

MCO Forms - forms@mycounselor.online added by MyCounselor Receptionist - forms@mycounselor.online as a CC'd Recipient Ip: 70.174.52.34

February 2, 2024 12:26 pm MDT

MCO Forms - forms@mycounselor.online added by MyCounselor Receptionist - forms@mycounselor.online as a CC'd Recipient Ip: 70.174.52.34

February 2, 2024 12:41 pm MDT

MCO Forms - forms@mycounselor.online added by MyCounselor Receptionist - forms@mycounselor.online as a CC'd Recipient Ip: 70.174.52.34