Authorization to disclose or obtain confidential client information

I hereby authorize Arohi Counseling, LLC to disclose / obtain protected medical information as described below from the records of:

Patient’s Last Name:

First:

M. Initial:

Address:

Date of birth:

Telephone Number:

To be disclosed to/obtain from: Name:

Address:

Telephone#

Fax #:

Reason for Disclosure/Obtaining Information:

Coordination of care

I understand that:
• This authorization may be revoked at any time by writing, except to the extent that information has already been disclosed. If information has already been disclosed in reliance on this authorization revoking it will only prevent further disclosure.
• Information (except drug and alcohol information) disclosure pursuant to this authorization may be subject to re- disclosure by the individual /organization identified
• Arohi Counseling, LLC and its designee are hereby released from any legal responsibility or liability for disclosure of the specified information.
• The Authorization may include Mental Health, Drug & Alcohol use, abuse, dependency and or HIV related information.
The information to be disclosed:
*****Check in box next to information you wish to have disclosed.

Authorization: Start Date

(Two years from today.) End Date

Signature of Client/Personal Representative

Date

Guardian Signature

Date

Signature of Witness

Date

Informed Consent to treatment

I have voluntarily chosen to receive treatment with Arohi Counseling, LLC or contractors (Provider), in a good therapeutic relationship. It is considered my right as well my duty to ask any questions and fully discuss the risks and benefits of any proposed treatment. It should also include the risks & benefits of any alternate treatment/or no treatment.

Patient’s /REP Signature:

Date

Patient’s Name:

Acceptance of Financial Responsibility:
I take full responsibility of the financial liability for the proposed services provided. I understand that the time is reserved in advance. If I don’t give at least 24-48 hours notice to cancel, I may be charged $70- $150. I’m responsible for co-pay, coinsurance, deductible, & non-covered services. There is a $5 charge for late payment of co pay. We charged $30 for any bounced bank check. I allow Arohi Counseling, LLC and its associates to bill my insurance company.

Patient’s Name:

Date

Patient’s /REP Signature:

Medical Records Release etc
I understand that the confidentiality of my records is protected, and release of information will be only by my written consent. Exceptions to confidentiality are as follows: a) local and state law may require reports of cases of child/minor/elderly abuse or neglect; b) if there is danger to self or others. C) Court order.
I understand that all records pertaining to my treatment may be released to my insurance company for claim processing, utilization review purposes, quality management or grievance/appeal process etc.

Patient’s Name:

Patient’s /REP Signature

Date

Guardian’s Name:

Guardian’s Signature:

Date

Patient Forms

Basic Information

Full Name

Sex

Male Female Unknown

Date of Birth

Primary Phone

Home Mobile Work

Phone Number

Social Security Number

Address Line 1

Address Line 2

City

State

Zip

Marital Status

Maiden Last

Driver's License State

Driver's License #

Demographics

Sexual Orientation

Gender Identity

Hispanic or Latino?

Yes No Decline to Specify

Ethnicity

Race

Language

Emergency Contact

Relationship to Contact

Full Name

Primary Phone

Home Mobile Work

Phone Number

Address Line 1

Address Line 2

City

State

Zip

Financial Information

Responsible Party

Who will be financially responsible for you?

Myself Someone else

If you chose “Someone Else”, please fill out the following:

Full Name

Primary Phone

Home Mobile Work

Method of Payment

What will be your method of payment?

Insurance Self-Pay

If you chose “Insurance”, please fill out the following:

PRIMARY INSURANCE POLICY

Insurance Company

Policy Number

Insurance Plan

Insurance Phone Number

Group Number

Insurance Company Address

Address Line 2

City

State

Zip

Relationship to Primary Policy Holder

If you are not the primary policy holder, please fill out the following:

Full Name

Sex

Male Female Unknown

Date of Birth

Policy ID Number

Social Security Number

Policy Holder Address

Address Line 2

City

State

Zip

If you are unable to provide your insurance information, please provide a reason before continuing.

SECONDARY INSURANCE POLICY

If you do not have a secondary insurance policy, you can leave this blank.

Insurance Company

Insurance Plan

Group Number

Insurance Company Address

Address Line 2

City

State

Zip

Relationship to Secondary Policy Holder

If you are not the secondary policy holder, please fill out the following:

Full Name

Sex

Male Female Unknown

Date of Birth

Insurance ID Number

Social Security Number

Policy Holder Address

Address Line 2

City

State

Zip

Authorization to disclose or obtain confidential client information

Informed Consent to treatment

Patient Forms

Basic Information

Demographics

Emergency Contact

Financial Information

Responsible Party

Additional Information

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