Client/Guardian Authorization for Use and Disclosure of Protected Health Information (PHI)

I, authorize Kardia Counseling & Consulting, PLLC at 325 Page Road, Pinehurst, NC 28370 Phone: (910) 295-0500 Fax: (910) 295-0503 to use, exchange, disclose or obtain certain protected health information (PHI) about me to/with:

Name:
Phone:
Address:
Fax:









* disclosure period limited to 6 months from date of consent





Redisclosure:
Once information is used or disclosed pursuant to this authorization, I understand that the federal privacy law, (45 CFR Parts 160 & 164) protecting PHI may not apply to the recipient and may not prohibit redisclosure. Other laws may prohibit redisclosure. When we disclose mental health and development disabilities information protected by the state law (GS 122C) or substance abuse treatment information protected by federal law (42 CFR Part 2) we must inform the recipient than disclosure is prohibited except as permitted or required by these two laws. Our notice of privacy practices describes the circumstances where disclosure is permitted or required by these laws.

Revocation and expiration:
I understand that I have the right to revoke this authorization at any time. My written revocation must be submitted to Shelwilbed O. Wray, LCAS, LMHC, LCMHC-Supervisor, at Kardia® Counseling & Consulting, PLLC (Privacy Officer). I understand I may refuse to sign this authorization form. I understand that Kardia® Counseling & Consulting, PLLC will not deny or refuse to provide treatment if I do not sign. This consent shall be valid for one year from the date signed unless noted below: