top of page
1156778_edited.jpg
FORMS

Authorization Form School

AUTHORIZATION FORM SCHOOL

This form when completed and signed by you, authorizes Cordell Associates, LLC, to release/receive protected information from your clinical record to/from the person you designate.

I authorize Cordell Associates, LLC, to release/receive (check one or both)
I am requesting Cordell Associates, LLC, to release/receive this information for the following reasons

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 disclosure).

or

You have the right to revoke this authorization, in writing, at any time by sending such written notification to this office address. However, your revocation will not be effective to the extent that this office has taken action in reliance on this authorization or it was obtained as a condition of obtaining insurance coverage and the insurer had a legal right to contest a claim.

 

I understand that this office 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 re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule

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.

Thanks for submitting!

bottom of page