Fillable Kathryn B. Miller, PhD Authorization For the Release

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Kathryn B. Miller, PhD Authorization For the Release

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Kathryn B. Miller, PhD
Licensed Psychologist
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Authorization For the Release of Clinical Information
Name:
Date of birth:
I authorize Kathryn B. Miller, Ph.D., L.P. to:
disclose to obtain from exchange with
(Person or organization with whom information will be exchanged)
(Address, phone number, fax)
The information will be used for:
Treatment planning Coordination/continuity of care “At the request of the individual”
Summary of history / diagnostic interview Clinical impressions and observations
Discharge summary and diagnosis Personal observations
Reports of psychological testing Psychotherapy notes
Other (specify):
This authorization shall remain in effect until (fill in expiration date) or until (fill in an event that relates to the
individual or the purpose of the use or disclosure).
You have the right to revoke this authorization, in writing, at any time by sending such written notification to my
office address or by signing below. However, your revocation will not be effective to the extent that I have taken
action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance
coverage and the insurer has a legal right to contest a claim.
I understand that Dr. Miller generally may not condition psychological services upon my signing an authorization
unless the psychological services are provided to me for the purpose of creating health information for a third
party.
I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by
the recipient of your information and no longer protected by the HIPAA Privacy Rule.
Signature of Patient Date
Date
(Signature of Parent / Legal Guardian if Patient is under 18 years of age)
If the authorization is signed by a personal representative of the patient, a description of such
representative’s authority to act for the patient must be provided.
Sign / date here to revoke this authorization: Date
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Kathryn B. Miller, PhD Authorization For the Release

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Completed 3 February 2021

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