ActionSteps Sample

Consent for Release of Confidential Information-

ActionSteps Counseling, Inc.




Person/agency to which information is being released or obtained

Consumer Information

The information authorized for release may include information which may indicate the presence of a communicable or venereal disease, which may include, but is not limited to, diseases such as Hepatitis, Syphilis, Gonorrhea, HIV, and AIDS.

Re: Psychiatric Records- Oklahoma State Law (760.D.Supp.1986, Sec.19) provides that psychological or psychiatric records may be provided to a patient if the treating physician or practitioner consents to the release or upon receipt of a court order. Therefore, records will not be released to patients, their guardians or agents (including attorneys) except with the consent of the treating practitioner, or upon receipt of a court order of competent jurisdiction.

The records requested may be protected under 42 CFR, Part 2, governing Alcohol and Drug Abuse records, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR parts 160 & 164, State Confidentiality Laws and regulations and cannot be released without my consent unless otherwise provided for by regulations. State and Federal law prohibits any further disclosure of such records without my specific written consent or when otherwise permitted by such regulation. I also understand that recipients of this information may re-disclose the information only in connection with their official duties.

For Criminal Justice System clients: Any disclosure made is bound by federal law and regulations governing Confidentiality of Drug Abuse Patient Records (42 USC 290dd-2; 42CFR, Part2) and that recipients of the information may receive and re-disclose it only in connection with their official duties with respect to the particular criminal proceeding and may not be used in other proceedings, for other purposes, or with respect to other individuals.

This consent expires on

Or one year from the date of my signature, or upon a written request to my clinician that it be revoked.

My signature indicates that I understand that all mental health and substance abuse treatment information, whether recorded or not, and all communications between consumer and therapist are both privileged and confidential and cannot be released without my authorization. I understand that treatment services are NOT contingent upon my decision to permit the release of information. I also understand that I am giving this release freely and voluntarily, and that I have the right to refuse to sign this consent. I understand that I may revoke this consent in writing at any time, except to the extent which actions have been taken in reliance upon it.

By Clicking Submit Below, you will be redirected to A Electronic Signature Contract that requires your signature.