Release of Information

This authorization is voluntary. I understand that Arbor Therapy Solutions, PLC, Natasha Lewis-Grinwis, LMSW, CST and Kris Lewis-Grinwis, LMSW will not base treatment, payment, enrollment, or eligibility for benefits on my signing this document. A separate form is required for release of psychotherapy progress notes unless indicated below. 

Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone Number *
Phone Number
I am the patient, or the legally authorized representative of the patient, listed above.
I request Arbor therapy Solutions, PLC, and Natasha Lewis-Grinwis, LMSW, CST or Kris Lewis-Grinwis, LMSW
to release my protected health information (or the information of the patient listed above) to:
Choose One *
If self, please complete with your own information
Address *
Address
Phone Number *
Phone Number
Fax Number
Fax Number
No information will be faxed if this information is not supplied
Purpose of release/disclosure to other person/organization *
If "other" box is checked, this field must be completed for form to be processed
Specific information to be released for the timeframe listed below *
Specific information to be released for the timeframe listed below
TO *
TO
I request the following information be released, which may include: alcohol and drug abuse/treatment; psychological and social work counseling; HIV, AIDS, or ARC; communicable disease or infections, including sexually transmitted infections, venereal disease, tuberculosis, and hepatitis; and demographic information for the purposes and conditions designated on this form: *
If "other" box is checked, this field must be completed for form to be processed
This authorization expires on *
This authorization expires on
Standard length of time is 6 months after date signed
Revoking Authorization:
1. I may revoke this authorization at any time.
2. Revocations must be made in writing and provided to Arbor Therapy Solutions, PLC and Natasha Lewis-Grinwis, LMSW, CST or Kris Lewis-Grinwis, LMSW via the postal service or in person.
3. Revocations will not apply to information that already has been released.
4. If this authorization was obtained as a condition of providing insurance coverage, the authorization will not apply to my insurance company to the extent the law provides my insurer with the right to contest a claim under the policy, or the policy itself.
I understand that once information has been disclosed, Arbor Therapy Solutions, PLC, Natasha Lewis-Grinwis, LMSW, CST, and Kris Lewis-Grinwis, LMSW can no longer protect it from further disclosure.
By typing my name and date below, together with providing the information above, I am signing this document electronically. This carries the same weight and authority as a paper signature. I affirm that I am not misrepresenting myself or my purposes in signing this document. *
By typing my name and date below, together with providing the information above, I am signing this document electronically. This carries the same weight and authority as a paper signature. I affirm that I am not misrepresenting myself or my purposes in signing this document.
Today's Date *
Today's Date