500 Mamaroneck Avenue, Suite 320 · Harrison, NY 10528
Phone: (914) 233-7177
Authorization for Release of Information
HIPAA-Compliant · 45 C.F.R. §§ 164.508 & 164.524
Notice: This authorization is voluntary. Your treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this form. You have the right to revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on it.
Section 1 — Patient Information
Section 2 — Direction of Disclosure
I authorize:
Richard J. DioGuardi, Ph.D. to release information to the provider/organization listed below
Richard J. DioGuardi, Ph.D. to receive information from the provider/organization listed below
Both — exchange information in both directions
Section 3 — Other Provider / Organization
Section 4 — Information to Be Disclosed
Type of information (check all that apply):
Psychological evaluation / testing report
Treatment summary / progress notes
Diagnosis / clinical impressions
Medication information
Intake / assessment records
School records / educational information
Discharge summary
Billing / insurance records
Verbal communication / phone consultation
Other (specify below)
Section 5 — Purpose of Disclosure
Purpose (check all that apply):
Coordination of care / treatment
Consultation with another provider
School or educational planning
Legal / court proceeding
Insurance / billing purposes
Personal records / at patient request
Other:
Section 6 — Expiration
This authorization will expire on (choose one):
Specific date:
Upon completion of the specific purpose described above
One (1) year from the date signed below
Section 7 — Special Categories of Information
Certain categories of health information receive additional legal protections under New York State law. Please initial next to any category you specifically authorize for disclosure. Leave blank if not applicable.
Mental health records (beyond standard psychotherapy notes)
Substance use / alcohol or drug treatment records (42 C.F.R. Part 2)
HIV/AIDS-related information
Genetic information
Section 8 — Your Rights
You have the right to:
Revoke this authorization at any time by submitting a written request to Dr. DioGuardi’s office. Revocation will not affect disclosures already made in reliance on this authorization.
Refuse to sign this authorization. Signing is voluntary and will not affect your treatment or eligibility for services.
Receive a copy of this signed authorization upon request.
Be informed if the recipient of this information is not covered by HIPAA and may re-disclose the information.
Section 9 — Signature
If the patient is a minor or lacks capacity to consent, the authorized representative must sign below and indicate their relationship to the patient.