AUTHORIZATION FOR RELEASE OF INFORMATION

1505 Orchid Avenue Winter Park, Florida 32789 (407) 644-4692 FAX (407)644-4882

I, *

understand that my participation in the counseling program at Hands of Hope of America, INC (HOHA), is free of charge to me. I understand that due to the relationship between LCS and HOHA, HOHA staff will be aware of my participation in the program in order to schedule appointments, track progress using pre/post test assessments and clinical progress as it relates to grant funding.

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I give my permission for Lutheran Counseling Services to consult with the staff at HOHA regarding the above information.
I do not give my permission for Lutheran Counseling Services to consult with the staff at HOHA regarding the above information.

I may revoke this consent by giving written notice to LCS at any time, and to the extent that action has been taken prior to such revocation, I release LCS from any and all liability.

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Signature of Patient/client *

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Today's Date *

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Signature of authorized LCS representative

Today's Date

NOTICE TO RECIPIENT OF INFORMATION: This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. If the records are so protected, Federal Regulation (42 CFR Part 2) prohibits 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 information 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.
1505 Orchid Avenue • Winter Park, Florida 32789
• (407) 644-4692 Fax: (407) 644-4882
Lutheran Counseling Services, Inc. is a Florida not-for-profit corporation
Website: LcsFL.com