Release of Information


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The following information: (Please check reports or information to be released)
Diagnosis
Medication
Progress & Treatment
Alcohol/Drug Related Information
Biopsychosoical history
Reason for Termination
Recommendations
# of kept/unkept appointments
Psychological Evaluation


The purpose for disclosure is:
To comply with court order
To comply with doctor referral
Treatment of patient
Collaboration with School


I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I have the right to revoke this authorization, in writing, at any time by sending such written notification to NorthStar Psychological + Consultation Services, LLC office address. However, my revocation will not be effective to the extent that NorthStar Psychological + Consultation Services, LLC has taken action on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed after the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule, and NorthStar Psychological + Consultation Services, LLC is not responsible for any subsequent disclosure. I understand that my psychotherapist generally may not condition treatment services upon my signing an authorization unless the psychotherapy services are provided to me for the purpose of creating health information for a third party.

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NorthStar Psychological + Consultation Services, LLC
429 E. Vermont Street
Suite 307
Indianapolis, IN 46202
Phone:
317-572-7847 (ST4R)
Fax:
317-632-3253
eMail:
info@northstarpsych.com
Hours:
Monday 3:00 pm to 8:00 pm & Tuesday through Thursday 8:00 a.m. to 8:00 p.m. Closed all other days.