Kimberly Klepec, MSW, LCSW

200 W. Monroe St., Suite 303B
Bloomington, IL 61701

Phone: (309) 319-1260

Fax: (309) 808-0560

HIPAA AUTHORIZATION FORM

I, , whose date of birth is , authorize Kimberly Kle-pec MSW, LCSW to disclose to and/or obtain from: the following information:

Description of Information to be Disclosed  (Patient/Client should initial each item to be disclosed.)

____    Assessment                            ____    Testing Information                 ____    Treatment Plan or Summary

____    Diagnosis                                ____    Educational Information          ____    Current Treatment Update

____    Psychosocial Evaluation         ____    Presence in Treatment           ____    Progress in Treatment

____    Psychological Evaluation        ____    Continuing Care Plan              ____    Other ________________

Revocation
I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Kimberly Klepec, MSW, LCSW at the above address. I further understand that a revocation of the au-thorization is not effective to the extent that action has been taken in reliance on the authorization.

Expiration
Unless sooner revoked, this authorization expires on .

Conditions
I further understand that Kimberly Klepec, MSW, LCSW will not condition my treatment on whether I give au-thorization for the requested disclosure. However, it has been explained to me that failure to sign this authori-zation may have the following consequences:

Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

Re-disclosure

Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. Other types of information may be re-disclosed by the recipient of the information in the following circumstances:

I will be given a copy of this authorization for my records.

Signature of Client


Date:


Signature of Parent, Guardian or Personal Representative


Date :


If you are signing as a personal representative of an individual, please describe your authority to act for this individual.

Signature of Provider


Date :