Authorization of Exchange of Information
Let's make a difference one person at a time.
I,
authorize LifeBridge Support, LLC to exchange information with:
Regarding my mental health and other services being provided at LifeBridge Support, LLC; social and emotional functioning; and any additional pertaining information. This exchange of information is for the sole purpose of treatment planning and evaluation, and the comprehensive coordination of care. I understand that this authorization expires one year from the date it was signed, unless revoked in writing prior to its expiration date.
I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to LifeBridge Support, LLC and my service provider. I understand that a revocation is not valid to the extent that LifeBridge Support, LLC has already acted in reliance on such authorization. This authorization is valid until one year from date signed unless revoked earlier. I understand that information will be disclosed only as determined necessary by my service provider. If records are released to lawyers in legal proceedings, I understand that information may be shared with any and all parties involved in the legal proceedings. In consideration of this consent, I hereby release the source of the records from any and all liability arising therefrom. A copy of this release shall have the same force and effect as the original.
Please email completed information to lifebridgesupport@gmail.com