Change in Entropy Hypnotherapy
Website: https://www.change-in-entropy.com/
Effective Date: March 17, 2026
Last Updated: March 17, 2026
Practice Contact Information
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180
1. Patient Information
Patient Full Name: ________________________________________
Date of Birth: ____________________________________________
Address: _________________________________________________
Phone: _________________________________________________
Email: _________________________________________________
2. Person or Entity Authorized to Release Information
I authorize:
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180
to use and/or disclose the protected health information described below. HIPAA allows the disclosing party and recipient to be identified by person, entity, or class of persons.
3. Person or Entity Authorized to Receive Information
I authorize Change in Entropy Hypnotherapy to disclose my information to:
Name of person, provider, organization, or class of recipient:
Address: _________________________________________________
Phone: _________________________________________________
Fax or Email (if applicable): ________________________________
4. Information to Be Released
Please check and complete all that apply. HIPAA requires a meaningful description of the information to be disclosed.
☐ Appointment records
☐ Intake forms
☐ Treatment summaries
☐ Progress notes
☐ Billing or payment records
☐ Dates of service: __________________________________________
☐ Entire designated record set maintained by the practice
☐ Other, specifically describe:
Special category
☐ Psychotherapy notes only
I understand psychotherapy notes receive special protection under HIPAA and generally require a separate authorization.
5. Purpose of Release
HIPAA requires a description of each purpose, but “at the request of the individual” is sufficient if the individual initiates the authorization and does not provide another purpose.
☐ At my request
☐ Continuity of care / consultation
☐ Insurance / payment matter
☐ Legal matter
☐ Personal records
☐ Other: _________________________________________________
6. Expiration
This authorization will expire on:
☐ Date: ______________________
or
☐ Event: _________________________________________________
An expiration date or expiration event is required for a valid authorization.
7. Important Rights and Notices
Please read and initial each item:
_____ I understand that I may revoke this authorization at any time by giving written notice to Change in Entropy Hypnotherapy, except to the extent action has already been taken in reliance on it. HIPAA requires the authorization to describe the right to revoke and any exceptions.
_____ I understand that information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA, depending on who receives it. HIPAA requires this notice where applicable.
_____ I understand that Change in Entropy Hypnotherapy generally may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization, except in limited circumstances permitted by law. HIPAA requires this statement.
_____ I understand this authorization is voluntary.
8. Method of Release
Please send the information by:
☐ Secure email
☐ Standard email
☐ Fax
☐ Mail
☐ In-person pickup
☐ Other: _________________________________________________
If sent electronically, send to: __________________________________
9. Signature
By signing below, I authorize Change in Entropy Hypnotherapy to use and/or disclose the protected health information described in this form as stated above.
Signature of Patient: ______________________________________
Date: __________________________________________________
10. Personal Representative, if Applicable
If signed by a personal representative, complete the following. HIPAA requires a description of the representative’s authority when someone other than the individual signs.
Name of Personal Representative: ____________________________
Relationship to Patient: ___________________________________
Authority to Act for Patient: ________________________________
Signature of Personal Representative: ________________________
Date: __________________________________________________
11. Practice Use Only
Date Received: ___________________________________________
Processed By: ____________________________________________
Date Completed: __________________________________________
Method Released: _________________________________________
Notes: __________________________________________________