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Nancy Nguyen, LCSW

Expanding Pathways · San Jose, California

Authorization for release of information

This form gives me permission to share your information with someone outside this practice, or to request information from them. You decide exactly what may be shared and with whom, and you can withdraw this permission at any time.

Client

Who may I exchange information with?

What am I authorized to do?

What information may be shared?

Check only the items you want shared. Anything left unchecked will not be released.

Under federal law, psychotherapy notes cannot be released on the same authorization as anything else. Checking this will clear the other selections, and you will need a separate form for those.

This authorization now covers psychotherapy notes only. Your other selections have been cleared, and those items are unavailable on this form. If you also want any of them released, uncheck psychotherapy notes here and complete a second copy of this form for the notes.

Purpose

This information may be used or disclosed in connection with mental health treatment, payment, or healthcare operations. If the purpose is something else, please describe it:

When does this expire?

Unless you revoke it sooner, this authorization ends on the date below, or when the event you describe occurs. Federal law requires one or the other.

Your rights

Revocation. You may revoke this authorization in writing at any time by notifying Nancy Nguyen, LCSW at (408) 805-4743, or in writing at the practice mailing address. A revocation does not undo anything already done in reliance on this authorization before it was received.

Conditions. Nancy Nguyen, LCSW will not condition your treatment on whether you sign this authorization. If declining to sign would have any consequence for the services you receive, that will be explained to you directly before you sign.

Form of disclosure. Unless you request otherwise in writing, information may be disclosed in any manner consistent with applicable law — verbally, on paper, or electronically.

Redisclosure. Information released under this authorization may be re-released by the person or organization receiving it, and at that point it may no longer be protected by HIPAA — unless a stricter state law applies. California law provides additional protections in many circumstances.

You will be given a copy of this authorization for your own records.

Signature

Who is signing?

Draw your signature above using your mouse, finger, or stylus.

Your completed authorization has downloaded. Please bring the PDF to your appointment, or send it back to Nancy Nguyen, LCSW using the secure method we discussed. Keep a copy for your own records.

Authorization for Release of Information · Expanding Pathways · Nancy Nguyen, LCSW. Completed entirely in your browser; nothing is transmitted or stored online.