Authorization for Emergency Contact Client InformationClient Legal Name* First Last Client Birth Date* MM slash DD slash YYYY Client Medicaid or Insurance #* Statement of AuthorizationI authorize Transformations Hope for Today's Families LLC, 4010 Dupont Circle Suite 582, Louisville KY 40207, phone/fax 502-899-5411, secure email office@transformationsllc.net, and its representatives, and the following person and/or organization: Name of Authorized Person* First Last Relationship to Client* Address of Authorized* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number of Authorized*Email Address of Authorized To share with one another the information from my Protected Health Healthcare Information, necessary to obtain prevention and treatment. I understand that the purpose of this authorization is to share information necessary to obtain emergency medical care. I understand that I may refuse to sign this authorization and that Transformations, LLC and its representatives will not allow my refusal to interfere with the receipt or payment of behavioral health services. I understand that refusal to complete and sign an authorization for emergency release will, by state regulations, prohibit the client from participating in Telehealth sessions. I understand that I may revoke this authorization, at anytime, in writing to Transformations at the address indicated above, except if Transformations or its representative has taken any action based on prior authorization, or obtained my authorization for the purpose of receiving reimbursement from a third party. This authorization will expire one year from the date of signing, or immediately following the revoking of the authorization . I understand that pursuant to KRS 304.17A-555-Patient’s Right of Privacy Regarding Mental health or Chemical Dependency-Authorization Disclosure, my Protected Health Information, used and /or shared under this authorization may not be shared by the recipient of the information beyond the purpose for which my authorization was given, without first obtaining my specific written consent to the re-disclosure. I understand that pursuant to 45 CFR 46.101(b.2) only data that has been separated from my child’s identifiable information may be used for research and program development purposes, unless written consent by signing an authorization form is provided. Click here for explanation of practices and services I have read and understand the above information and am legally qualified to authorize the sharing of this protected healthcare information.* Yes Signature of Client or Legal Guardian*Name of Person Signing* First Last Relationship to Client* Email Address* Date of Signature* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
