Consent For Treatment

I understand that all health and clinical information is treated with strict confidentiality. No information related to the client, either verbal or written, will be released to other agencies or individuals without the express written consent of the client’s legal guardian. However, confidential information will need to be released to the funding source in order to process claims and obtain reimbursement.

1. I authorize Counseling Resource Services and it’s rendering provider, listed below, to obtain and release information, regarding my treatment to any care provider/family member who presents a valid need for such information as determined by the provider.
2. I authorize release of medical information necessary to process claims for services rendered on my behalf. For these services I authorize payment directly to the Counseling Resource Services provider listed below by Medicare, health insurance, or third party benefits.

By law, the rules of confidentiality do not hold under the following conditions:

3. If abuse or neglect of a minor, disabled, or elderly person is reported or suspected, the professional involved is required to report it to the Department of Children & Families for investigation.
4. If, during the course of services, the professional involved receives information that someone’s life is in danger, that professional has a duty to warn the potential victim.
5. If our records or staff testimony are subpoenaed by court order, we are required to produce records or appear in court and answer questions regarding the client.

The information on this page has been explained to me. I understand that I may revoke consent for the above at any time, however I cannot revoke consent for action that has already been taken. A copy of this release shall be valid as the original.

*Please upload insurance card and a form of identification prior to submitting.  Accepted upload files: JPEG, PNG, GIF