HIPAA Release Form

This form allows your psychologist at Nassau Psychology Dynamic P.C. to speak with another person or organization (such as a school, physician, or family member) about your or your child’s psychological services. You can choose what information may be shared and for what purpose. You may revoke this authorization in writing at any time. Psychotherapy notes are not included. Please note that once information is shared, it may no longer be protected by HIPAA.

Client Full Name(Required)

Date of Birth(Required)

Client Phone

Client Email

Authorized Recipient Name / Organization(Required)

Recipient Relationship to Client

Recipient Phone

Recipient Email

Information Authorized for Disclosure (Psychotherapy notes excluded)(Required)

Scheduling and attendance information

Diagnosis and dates of treatment

Treatment plan goals and progress summaries

Psychological testing and assessment summaries

Billing and insurance information

Care coordination and professional consultation

Additional or Specific Information (optional)

Purpose of Disclosure(Required)

Expiration(Required)

Name of Person Signing(Required)

Relationship to Client(Required)

Electronic Signature(Required)

Date Signed(Required)

Revocation Acknowledgment(Required)

I understand I may revoke this authorization in writing at any time, except to the extent action has already been taken.

Redisclosure Acknowledgment(Required)

I understand information disclosed may be subject to redisclosure and may no longer be protected by HIPAA.

Electronic Signature Consent(Required)

I consent to using my typed or drawn name as my electronic signature.

HIPAA Release Form

Evaluation Types

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