Hipaa Authorization From

Consent for Release of Information

Please fill out Online or Download and bring in

I, (enter your name) authorize any representative of Corner Canyon Counseling & Psychological Services to

the following documents, or information

Documents to be included in this request:
Entire medical or psychological record, except psychotherapy notesSummary report or letterTreatment plan onlyProcess notes onlyPsychological reportsTesting dataAcademic testing and/or reportMedical recordsInsurance recordsDisability testing resultsVocational testing results

The above information will be used for the following purposes:
Select your choices:

I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually
Identifiable Health Information, Parts 160 and 164) and Title 45 (Rules of Confidentiality of Alcohol and Drug Abuse
Patient Records), plus applicable state laws. I further understand that the information disclosed to the recipient may not
be protected under these guidelines if they are not a health care provider covered by state or federal rules.

I understand that this authorization is voluntary and I may revoke this consent at any time by providing written notice.
This notice will no longer be valid 6 months after final date of service. I have been informed what information will be
given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this
authorization. I understand that I have a right to refuse to sign this authorization.

If you are the legal guardian or representative appointed by the court for the patient, please attach a copy of the legal
documentation to this authorization.

We'll have you hand sign this when you com into the office.
Patient's Signature (required)
First Name: Last Name:

Parent, guardian, of legal representative signature
First Name: Last Name:

Phone: 801.438.6059 | Fax: 801.501.0249

Draper Office

248 East 13800 South, #4
Draper, UT 84020

Bluffdale Office

14241 South Redwood Road Suite 100
Bluffdale, UT 84065