Release of Health Information Melissa Lester LCSW

Release of Health Information

RELEASE OF INFORMATION TO THIRD PARTIES

If you are requesting and authorizing me to communicate verbally or in writing with any third party regarding your treatment, including acknowledging that you are a client, this form must be completed in its entirety.

The following is an authorization for the parties named below to consult regarding your treatment process. Information shared is for the sole purpose of facilitating maximum care to you as the client.

I, (your name)

, authorize Melissa Lester, LCSW and the following parties to discuss my mental health treatment information and records obtained in the course of psychotherapy treatment, including, but not limited to:

a. Dates of scheduled appointments as well as attendance (+/-) at each

b. Invoice, billing and payment information

c. Clinical information for the sole purpose of enhancing your treatment outcomes

1) Name

Phone

2) Name

Phone

3) Name

Phone

Please indicate your preference regarding the information to be shared:

The parties above may discuss my medical and/or mental health information without limitations

I prefer to limit the information shared. The limitations I would like to make are as follows:

Your signature below indicates that you understand you have a right to receive a copy of this authorization and that you are aware that any cancellation or modification of this authorization must be made in writing to the above email address and received and opened by me before any disclosures are made.

Signature

Date Consent Begins

Date Consent Ends

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