Erik Bohlin, M.A. LMHC

AUTHORIZATION FOR USE OR DISCLOSUREOF PROTECTED HEALTH INFORMATION

 FOR PURPOSES REQUESTED BY PATIENT / REPRESENTATIVE

Type of Information to be Disclosed:

I hereby authorize Erik Bohlin, M.A. to use and/or disclose the following protected health information:

q Records - outside health provider                                 q Telephone Consult of current issues

q ______________________________                            q ________________________________________

Purpose:  Patient Request

Recipient of Protected Health Information:

Deliver By

q  Mail     q  Fax (      ) _____________  q  Phone (     ) __________________    q  E-Mail  ________________

Revocation / Redisclosure:

It is my understanding that this authorization can be revoked in writing at any time, except to the extent that substantial action may have already occurred based on prior authorization, and/or including provision of health care services requiring disclosure to effectuate payment.  Unauthorized redisclosure by recipient is a potential risk.

Duration:

If not previously revoked, this authorization will expire: ________________________________________________

(must specify date, event, or condition)

Specific Limitation:  Except as to third-party payers, this authorization does not include disclosure for future health care services received more than ninety (90) days from date of last signature.

Signature:

This Authorization covers protected health information pertaining to _____________________________________.

Signature below authorizes use and/or disclosure of protected health information in accordance with the foregoing from the Date of that signature (initial or renewal). I understand that I have the right to refuse to sign this authorization and that my refusal will not condition treatment, payment, enrollment or eligibility for benefits.