{"id":294,"date":"2026-03-17T14:59:33","date_gmt":"2026-03-17T14:59:33","guid":{"rendered":"https:\/\/www.change-in-entropy.com\/?page_id=294"},"modified":"2026-03-17T14:59:55","modified_gmt":"2026-03-17T14:59:55","slug":"hipaa-authorization-for-release-of-information","status":"publish","type":"page","link":"https:\/\/www.change-in-entropy.com\/index.php\/hipaa-authorization-for-release-of-information\/","title":{"rendered":"HIPAA Authorization for Release of Information"},"content":{"rendered":"\t\t
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Change in Entropy Hypnotherapy<\/strong>
Website:<\/strong> https:\/\/www.change-in-entropy.com\/<\/a>
Effective Date:<\/strong> March 17, 2026
Last Updated:<\/strong> March 17, 2026<\/p>

Practice Contact Information<\/strong>
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: jennifer@change-in-entropy.com<\/a>
Phone: (907) 278-1180<\/p>

1. Patient Information<\/h2>

Patient Full Name:<\/strong> ________________________________________<\/p>

Date of Birth:<\/strong> ____________________________________________<\/p>

Address:<\/strong> _________________________________________________<\/p>

Phone:<\/strong> _________________________________________________<\/p>

Email:<\/strong> _________________________________________________<\/p>

2. Person or Entity Authorized to Release Information<\/h2>

I authorize:<\/p>

Change in Entropy Hypnotherapy<\/strong>
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: jennifer@change-in-entropy.com<\/a>
Phone: (907) 278-1180<\/p>

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.<\/p>

3. Person or Entity Authorized to Receive Information<\/h2>

I authorize Change in Entropy Hypnotherapy to disclose my information to:<\/p>

Name of person, provider, organization, or class of recipient:<\/strong><\/p>

Address:<\/strong> _________________________________________________<\/p>

Phone:<\/strong> _________________________________________________<\/p>

Fax or Email (if applicable):<\/strong> ________________________________<\/p>

4. Information to Be Released<\/h2>

Please check and complete all that apply. HIPAA requires a meaningful description of the information to be disclosed.<\/p>

\u2610 Appointment records
\u2610 Intake forms
\u2610 Treatment summaries
\u2610 Progress notes
\u2610 Billing or payment records
\u2610 Dates of service: __________________________________________
\u2610 Entire designated record set maintained by the practice
\u2610 Other, specifically describe:<\/p>

Special category<\/h3>

\u2610 Psychotherapy notes only<\/strong>
I understand psychotherapy notes receive special protection under HIPAA and generally require a separate authorization.<\/p>

5. Purpose of Release<\/h2>

HIPAA requires a description of each purpose, but \u201cat the request of the individual\u201d is sufficient if the individual initiates the authorization and does not provide another purpose.<\/p>

\u2610 At my request
\u2610 Continuity of care \/ consultation
\u2610 Insurance \/ payment matter
\u2610 Legal matter
\u2610 Personal records
\u2610 Other: _________________________________________________<\/p>

6. Expiration<\/h2>

This authorization will expire on:<\/p>

\u2610 Date: ______________________
or
\u2610 Event: _________________________________________________<\/p>

An expiration date or expiration event is required for a valid authorization.<\/p>

7. Important Rights and Notices<\/h2>

Please read and initial each item:<\/p>

_____ 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.<\/p>

_____ 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.<\/p>

_____ 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.<\/p>

_____ I understand this authorization is voluntary.<\/p>

8. Method of Release<\/h2>

Please send the information by:<\/p>

\u2610 Secure email
\u2610 Standard email
\u2610 Fax
\u2610 Mail
\u2610 In-person pickup
\u2610 Other: _________________________________________________<\/p>

If sent electronically, send to: __________________________________<\/p>

9. Signature<\/h2>

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.<\/p>

Signature of Patient:<\/strong> ______________________________________<\/p>

Date:<\/strong> __________________________________________________<\/p>

10. Personal Representative, if Applicable<\/h2>

If signed by a personal representative, complete the following. HIPAA requires a description of the representative\u2019s authority when someone other than the individual signs.<\/p>

Name of Personal Representative:<\/strong> ____________________________<\/p>

Relationship to Patient:<\/strong> ___________________________________<\/p>

Authority to Act for Patient:<\/strong> ________________________________<\/p>

Signature of Personal Representative:<\/strong> ________________________<\/p>

Date:<\/strong> __________________________________________________<\/p>

11. Practice Use Only<\/h2>

Date Received:<\/strong> ___________________________________________<\/p>

Processed By:<\/strong> ____________________________________________<\/p>

Date Completed:<\/strong> __________________________________________<\/p>

Method Released:<\/strong> _________________________________________<\/p>

Notes:<\/strong> __________________________________________________<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"

Change in Entropy HypnotherapyWebsite: https:\/\/www.change-in-entropy.com\/Effective Date: March 17, 2026Last Updated: March 17, 2026 Practice Contact InformationChange in Entropy Hypnotherapy2862 Change Street, Unit ALos Alamos, NM 87544Email: jennifer@change-in-entropy.comPhone: (907) 278-1180 1. Patient Information Patient Full Name: ________________________________________ Date of Birth: ____________________________________________ Address: _________________________________________________ Phone: _________________________________________________ Email: _________________________________________________ 2. Person or Entity Authorized to Release Information I […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-294","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages\/294","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/comments?post=294"}],"version-history":[{"count":4,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages\/294\/revisions"}],"predecessor-version":[{"id":298,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages\/294\/revisions\/298"}],"wp:attachment":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/media?parent=294"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}