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Authorization To Release/ Receive Information

Please take a moment to fill out the form.

This authorizes TGIF Counseling, LLC to release/receive, in writing or through telephone contact, general medical, psychological/psychiatric information including alcohol/drug abuse or addiction from my record in accordance with Georgia’s Statutes and the State of Georgia and Federal Administration Rules and Regulations to/from: 

Information to be:
Information to be:
Purpose of Release:
Release Duration:

All information I hereby authorize to be obtained from or released to TGIF Counseling, LLC will be held strictly confidential and cannot be released by the recipient without my written consent. I understand that this authorization will remain in effect unless I specify an expiration date. If this release is for court-ordered psychological evaluation, it is understood that the report will be used as evidence in court. The psychological evaluation report will be released to the referring agency/ attorney and you may request information from that agency of attorney. It is understood that this consent is subject to revocation at any time by the undersigned except to the extent that action has already been taken in compliance with this consent.
Notice of Prohibition on Redisclosure: This information had been disclosed to you from records protected by Federal Rules governing confidentiality rules (42 CFR part 2). The federal Rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other investigations is not sufficient for this purpose. The Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
I hereby release TGIF Counseling, LLC from all legal responsibility that may arise from the release of the above-requested information. This authorization is fully understood and it is made voluntarily and with informed consent on my part.

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