{"id":409,"date":"2024-06-21T10:51:35","date_gmt":"2024-06-21T10:51:35","guid":{"rendered":"https:\/\/demolinks2.com\/baffour-agyeman\/?page_id=409"},"modified":"2024-06-21T10:53:38","modified_gmt":"2024-06-21T10:53:38","slug":"release-of-information","status":"publish","type":"page","link":"https:\/\/demolinks2.com\/baffour-agyeman\/release-of-information\/","title":{"rendered":"Release of Information"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column]\t\t<div id=\"wd-66755b45dba3b\" class=\"wd-image wd-wpb wd-rs-66755b45dba3b text-center  refrl-frm-img\">\n\t\t\t\n\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"1239\" height=\"938\" src=\"https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/uploads\/2024\/04\/WDD-US-21032024-56483221334-Resilience-Psychiatry-01.png\" class=\"attachment-full size-full\" alt=\"\" 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mobile_bg_img_hidden=&#8221;no&#8221; tablet_bg_img_hidden=&#8221;no&#8221; woodmart_parallax=&#8221;0&#8243; woodmart_gradient_switch=&#8221;no&#8221; woodmart_box_shadow=&#8221;no&#8221; wd_z_index=&#8221;no&#8221; woodmart_disable_overflow=&#8221;0&#8243; row_reverse_mobile=&#8221;0&#8243; row_reverse_tablet=&#8221;0&#8243;][vc_column]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_7' ><div id='gf_7' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_7' id='gform_7'  action='\/baffour-agyeman\/wp-json\/wp\/v2\/pages\/409#gf_7' data-formid='7' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_1\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Release of Information Consent<\/h2><\/div><div id=\"field_7_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_3'>Client&#039;s name:<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_7_3' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I authorize [NAME OF PRACTICE or CLINICIAN&#039;S NAME] to:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_5'>\n\t\t\t<div class='gchoice gchoice_7_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Send'  id='choice_7_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_5_0' id='label_7_5_0' class='gform-field-label gform-field-label--type-inline'>Send<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Receive'  id='choice_7_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_5_1' id='label_7_5_1' class='gform-field-label gform-field-label--type-inline'>Receive<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >The following information:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_6'><div class='gchoice gchoice_7_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Medical history and evaluation(s)'  id='choice_7_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_1' id='label_7_6_1' class='gform-field-label gform-field-label--type-inline'>Medical history and evaluation(s)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Mental health evaluations'  id='choice_7_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_2' id='label_7_6_2' class='gform-field-label gform-field-label--type-inline'>Mental health evaluations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='Developmental and\/or social history'  id='choice_7_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_3' id='label_7_6_3' class='gform-field-label gform-field-label--type-inline'>Developmental and\/or social history<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.4' type='checkbox'  value='Educational records'  id='choice_7_6_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_4' id='label_7_6_4' class='gform-field-label gform-field-label--type-inline'>Educational records<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.5' type='checkbox'  value='Progress notes, and treatment or closing summary'  id='choice_7_6_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_5' id='label_7_6_5' class='gform-field-label gform-field-label--type-inline'>Progress notes, and treatment or closing summary<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.6' type='checkbox'  value='Other'  id='choice_7_6_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_6' id='label_7_6_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_7'>To \/ From:<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_7_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_8'>Phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_7_8' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Your relationship to client:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_9'>\n\t\t\t<div class='gchoice gchoice_7_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Self'  id='choice_7_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_9_0' id='label_7_9_0' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Parent\/legal guardian'  id='choice_7_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_9_1' id='label_7_9_1' class='gform-field-label gform-field-label--type-inline'>Parent\/legal guardian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Personal representative'  id='choice_7_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_9_2' id='label_7_9_2' class='gform-field-label gform-field-label--type-inline'>Personal representative<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_9_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Other'  id='choice_7_9_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_9_3' id='label_7_9_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >The above information will be used for the following purposes:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_10'>\n\t\t\t<div class='gchoice gchoice_7_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Planning appropriate treatment or program'  id='choice_7_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_0' id='label_7_10_0' class='gform-field-label gform-field-label--type-inline'>Planning appropriate treatment or program<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Continuing appropriate treatment or program'  id='choice_7_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_1' id='label_7_10_1' class='gform-field-label gform-field-label--type-inline'>Continuing appropriate treatment or program<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Determining eligibility for benefits or program'  id='choice_7_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_2' id='label_7_10_2' class='gform-field-label gform-field-label--type-inline'>Determining eligibility for benefits or program<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_10_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Case review'  id='choice_7_10_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_3' id='label_7_10_3' class='gform-field-label gform-field-label--type-inline'>Case review<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_10_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Updating files'  id='choice_7_10_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_4' id='label_7_10_4' class='gform-field-label gform-field-label--type-inline'>Updating files<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_10_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Other'  id='choice_7_10_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_5' id='label_7_10_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_11\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >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 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), 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.<br><br>\n\nI understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. 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.<br><br>\n\nIf you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.<\/div><div id=\"field_7_12\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_12'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_7_12_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_7_12_valid' id='input_7_12_valid' \/><canvas id='input_7_12' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_7_13\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_13'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_7_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_7_13_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_13' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_7_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_14'>Witness signature (if client is unable to sign):<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_7_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_15'>Witness Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_7_15' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_7_15_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_15_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_15' class='gform_hidden' value='https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_7' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> 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