Melinda Macht-Greenberg, PhD

Licensed Psychologist

209 Burlington Road

Bedford, MA 01730

781-879-5363

AUTHORIZATION FORM

 

Client Name_________________

Client DOB__________________

 

This form when completed and signed by you, authorizes Dr. Macht-Greenberg to obtain, release, and/or share protected health information from your clinical record from/to the person you designate.  This form is to be signed by a parent/guardian if the client is a minor.

 

I authorize Melinda Macht-Greenberg, PhD to share information with:

Name of Person to Contact___________________

Contact Information_________________________

 

I am requesting Dr. Macht-Greenberg obtain, release and share this information “at my request” if there is no one specific reason or for only the specific following reason:  ______________________.

 

The authorization shall remain in effect until the following date or event. If the client wishes they may indicate that there is no expiration date for the authorization.

______________________.

 

The client has the right to revoke this authorization in writing at any time by sending such written notification to Dr. Macht-Greenberg’s office address.  However, your revocation will not be effective to the extent that Dr. Macht-Greenberg has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

 

I understand that a psychologist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. 

 

I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected by the HIPAA Privacy Rule.

 

Signature of Client or Parent/Guardian____________________________

Date___________________________

 

If the authorization is signed by a personal representative of the client, a description of such representative’s authority to act for the client must be provided (e.g. parent or guardian) _________________________.