• I, (client name)
  • I understand that these services may be in the form of Therapeutic Interventions, Assessment, Treatment Planning, and Psychiatric Services.

    I also understand that all clinical information will be kept confidential, except as stipulated in Florida Statutes 39, 394 and the Health Insurance Portability and Accountability Act as described in the Privacy Notice. The clinical record is the property of and will be retained by HEADS.

    Only authorized personnel of HEADS may review my clinical record for the purpose of clinical provision, supervision, consultation, auditing, compliance, and billing. Portions of my information will be provided to my insurance company to be used for billing and payment purposes. This notice will be kept for a period of eight (8) years.

    I acknowledge receipt of HEADS Clients Rights and Responsibilities. I have been given the opportunity to ask questions and I understand my rights and responsibilities. I have been informed by HEADS’s staff of the services available through HEADS and agree to participate.

    I may revoke my consent in writing for any or all services at any time.

  • I understand that this consent is valid for one year and that I have the right to rescind this consent at any time.

    You have the right to revoke this authorization, in writing, at any time per HIPAA Privacy Policy 164.520, with the exception of those authorizations you signed for routine disclosures for treatment, payment or healthcare operations as permitted by the HIPAA Privacy Rule. HEADS will not condition your treatment, payment, enrollment or eligibility on whether or not you sign this release of information. Be advised that there is potential for your information to be redisclosed by the recipient and no longer protected by 45 CFR, Part 164, Subpart E.

  • Date Format: MM slash DD slash YYYY