Please download and complete the forms below if you are a new Client:
CPI may disclose, release and exchange information about:
By signing I acknowledge that such release discloses the fact that mental health/health services have been/are being provided.
This disclosure of information* is required for the following purpose(s): ): (check applicable areas)
and shall be limited to releasing the following types of information (initial all applicable areas):
or any information/records indicated, regardless of date.
This authorization may be revoked in writing by the undersigned at any time except, to the extent that action has already been taken. If not revoked, it shall terminate in one year. Once this information is disclosed, how the recipient further discloses it may no longer be protected under federal privacy law (HIPAA).
I understand that I may receive a copy of this authorization.
*For CPI Office Personel Only*
RECORD OF RELEASE OF INFORMATION
The following information was released to the named party specified on the front of this form. Identify the specific dates of the reports, records, items released.
Please print out this page after you have filled it out, then sign it and bring it with you on your first visit.