Release of Info (BiLateral Auth)

Bilateral Authorization to Exchange
Professional Information

(Release of Information)

"*" indicates required fields

This form fully protects your civil liberties and abides by standards within the Health Insurance Portability and Accountability Act (HIPAA) when the following conditions are met:

All blanks have been filled out prior to your signing it;
Signing this is not required as a condition of treatment unless Rachel W. Koppa, PhD, LPC-S, LMFT professional and/or ethical codes require her to disclose information;
That you sign it only after a specific request for information has been made;
That you fully understand that the release is limited to include only the agency (or agencies) or individual(s) named below.

I AUTHORIZE: Rachel W. Koppa, PhD, LPC-S, LMFT

TO EXCHANGE PROFESSIONAL INFORMATION WITH:*

IN REGARD TO (CLIENT NAME):*

FOR THE PURPOSE OF: TREATMENT COLLABORATION

Any information you authorize other professionals to release to Rachel W. Koppa, PhD, LPC-S, LMFT will be held strictly confidential and will not be released without your permission This authorization expires in 90 days from the date below, and you may revoke it at any time and for any reason by telling, Rachel W. Koppa, PhD, LPC-S, LMFT. Please keep in mind that information disclosed under this authorization may be re-disclosed by the identified person(s) above and may no longer be protected by our therapeutic confidentiality.

By signing below, I acknowledge that I have read, understand, and agree to the Bilateral Authorization to Exchange Professional Information

I Accept

Printed Client Name:*

Please enter your full name in the textbox below to authorize this exchange of information
(Client's Parent/Guardian if under 18)

I understand that by typing my name and clicking on "Submit", I am electronically signing this document.

Please enter contact for the person to release information to:

Contact Email:

Contact Phone Number:

Koppa Counseling

Bilateral Authorization to Exchange Professional Information

I AUTHORIZE: Rachel W. Koppa, PhD, LPC-S, LMFT

FOR THE PURPOSE OF: TREATMENT COLLABORATION

Please enter contact for the person to release information to:

Bilateral Authorization to Exchange
Professional Information