JAN SANTORA-FARRAR, MA
Licensed Mental Health Counselor #00010966
jan.santora1@gmail.com
206.233.1021
AUTHORIZATION TO EXCHANGE CONFIDENTIAL INFORMATION
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I, (Name of patient) ________________________________________________________
(Date of birth) ______________________ (hereinafter “Patient”) authorize (Name of provider) ________________________________________________________________
(hereinafter “Provider”) to exchange confidential information regarding my treatment with Jan Santora-Farrar to:
________________________________________________________________________
________________________________________________________________________
(Name and function of the person or entities to which information is to be exchanged)
This authorization permits the exchange of the following information:
_____ Any and all information necessary
_____ Diagnosis
_____ Progress to date
_____ Patient records
_____Treatment plan
_____ Clinical test results
_____ Summary of treatment
_____ Prognosis
_____ Dates of treatment
_____ Other
I authorize the exchange of information described above for the following purpose:
_________________________________________________________________________
The recipient may use the information above solely for the following purposes:
_________________________________________________________________________
I understand that I have a right to receive a copy of this authorization. I also understand that any cancellation or modification of this authorization must be in writing. I understand that I have the right to revoke this authorization at any time less Provider has taken action in reliance upon it. I also understand that such revocation must be in writing and received by Provider to be effective. This authorization shall remain valid until:
_________________________________________________________________________
(Client signature) ____________________________________________________________
(Client printed name) _________________________________________________________
Date ______________________________________________________________________