Release of Information - BraveOne.com

AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL MENTAL HEALTH INFORMATION (HIPPA)

Please review and fill out the form.

Name*
First Last
Phone Number*
Date of Birth:*
Month
Day
Year
B1C Team Member:*
Is authorized to release and disclose information to (name of professional or group you're authorizing your B1C Team Member to talk to or share with):*
Also (name of professional or group you're authorizing to talk to your B1C Team Member):
is authorized to release and disclose information to (name of B1C Team Member):
Professional's Phone Number*
Professional's Email Address*
Specific Information to be Released/Obtained (Please select only one):*
- All health/mental health/personal information including goals for care.
- All health/mental health/personal information including goals for care except for:
- Only the following records or type of information:
Types of records to be replaced.*
Types of records to be replaced.*
This disclosure of information authorized by me is required for the following purpose:*
Other Following Purpose:*
This Authorization shall expire in...*
This Authorization shall become effective on the below date and will expire in one year.
MM slash DD slash YYYY

Enter Today's Date
This Authorization shall become effective on the below date and will never expire.*
MM slash DD slash YYYY

Enter Today's Date
A Photocopy, email copy, or facsimile of this form is to be considered as valid as the original.

Please note: If you have authorized the disclosure of your personal information or mental health information to someone who is not legally required to keep it confidential, it may be redisclosed and may no longer be protected. State law varies as to prohibiting recipients of your health information from redisclosing such information except with your written authorization or as specifically required or permitted by law. Please check with your state to determine HIPPA requirements and regulations.

Your Rights:
- You may refuse to sign this Authorization.
- You may revoke this Authorization only by delivering your revocation in writing to the BraveOne Team and, if applicable, your BraveOne Coach. Your revocation will be effective when the BraveOne Team and, if applicable, your BraveOne Coach receives it. However, this revocation will not extend to information that was already obtained or released (used or disclosed) prior to the revocation.
- You have the right to receive a copy of this Authorization.
Signature (please type your full name):*
Date:*
MM slash DD slash YYYY

Enter Today's Date
Email Address (Please use the one you joined the B1C with):*

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