{"id":14317,"date":"2025-05-09T13:25:48","date_gmt":"2025-05-09T20:25:48","guid":{"rendered":"https:\/\/siliconvalleymarriagecounseling.com\/?page_id=14317"},"modified":"2025-07-28T14:50:26","modified_gmt":"2025-07-28T21:50:26","slug":"authorization-to-release-information-portland","status":"publish","type":"page","link":"https:\/\/cms-staginglink3.com\/aziza-client-site\/portland\/authorization-to-release-information-portland\/","title":{"rendered":"Authorization to Release Information"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"14317\" class=\"elementor elementor-14317\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7e57a38 e-flex e-con-boxed e-con e-parent\" data-id=\"7e57a38\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-10dce84 elementor-widget elementor-widget-spacer\" data-id=\"10dce84\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a8c9818 elementor-widget elementor-widget-text-editor\" data-id=\"a8c9818\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<h1><span style=\"color: #ffffff;\">Authorization to Release Information<\/span><\/h1>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3f462f0 elementor-widget elementor-widget-spacer\" data-id=\"3f462f0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-6ca0315f e-flex e-con-boxed e-con e-parent\" data-id=\"6ca0315f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-058fcdb elementor-widget elementor-widget-spacer\" data-id=\"058fcdb\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-48ee854 fluent-form-widget-step-header-yes fluent-form-widget-step-progressbar-yes fluentform-widget-submit-button-custom elementor-widget elementor-widget-fluent-form-widget\" data-id=\"48ee854\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"fluent-form-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n            <div class=\"fluentform-widget-wrapper fluentform-widget-custom-radio-checkbox fluentform-widget-align-default\">\n\n            \n            <div class='fluentform ff-default fluentform_wrapper_13 ffs_default_wrap'><form data-form_id=\"13\" id=\"fluentform_13\" class=\"frm-fluent-form fluent_form_13 ff-el-form-top ff_form_instance_13_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_13_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Authorization to release information (Portland)<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='14317' \/><input type=\"hidden\" id=\"_fluentform_13_fluentformnonce\" name=\"_fluentform_13_fluentformnonce\" value=\"06dbb8d301\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/aziza-client-site\/wp-json\/wp\/v2\/pages\/14317\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-13_1\" ><h3 class='ff-el-section-title'>AUTHORIZATION TO RELEASE INFORMATION<\/h3><div class='ff-section_break_desk'><p class=\"\" data-start=\"125\" data-end=\"412\">This form allows you to give permission for Azizeh E, Rezayian, MA, LMFT, to share specific information from your mental health treatment with a person or organization you name.<\/p>\n<p class=\"\" data-start=\"414\" data-end=\"505\">You are not required to sign this form. Signing is voluntary and will not affect your care.<\/p><\/div><hr \/><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-13_2\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>Patient Information<\/h4><\/div><hr \/><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_names_first_name_' id='label_ff_13_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_13_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_names_last_name_' id='label_ff_13_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_13_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_13_input_text' id='label_ff_13_input_text' aria-label=\"Provider Name\">Provider Name <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" placeholder=\"Azizeh E. Rezayian, MA, LMFT\" data-name=\"input_text\" id=\"ff_13_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-13_3\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>Recipient of Information (Name of person or organization to receive information):<\/h4><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_13_input_text_2' id='label_ff_13_input_text_2' aria-label=\"Recipient Name 1\">Recipient Name 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_13_input_text_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_input_text_1' id='label_ff_13_input_text_1' aria-label=\"Recipient Name 2 (if required)\">Recipient Name 2 (if required)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_13_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-13_4\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>Purpose of Disclosure<\/h4><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_13_description' id='label_ff_13_description' aria-label=\"Briefly explain why you are authorizing the release of this information (e.g., coordination of care, legal purposes, personal request).\">Briefly explain why you are authorizing the release of this information (e.g., coordination of care, legal purposes, personal request).<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"true\" aria-labelledby=\"label_ff_13_description\" name=\"description\" id=\"ff_13_description\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-13_5\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>Specific Uses and Limitations:<\/h4><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Check all that apply:\">Check all that apply:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_21e20608bf05ecd938a25b6f5b4a7314'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Clinical Evaluation\"  id='checkbox_21e20608bf05ecd938a25b6f5b4a7314' aria-label='Clinical Evaluation' aria-invalid='false' aria-required=true> <span>Clinical Evaluation<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_e22c6ec49f67a915387d2a69033c9996'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Clinical Treatment\"  id='checkbox_e22c6ec49f67a915387d2a69033c9996' aria-label='Clinical Treatment' aria-invalid='false' aria-required=true> <span>Clinical Treatment<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-13_6\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p class=\"p1\">Such disclosure shall be limited to the following specific types of information:<\/p>\n<p class=\"p1\">Clinical Observations, diagnoses, treatment goals, information related to my treatment of this patient.<\/p><\/div><hr \/><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-13_7\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h3>Acknowledgements<\/h3><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Please read and confirm each statement:\">Please read and confirm each statement:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_4dabf4c5f7d2332a0aede129db862ff5'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\" I understand that I have the right to receive a copy of this authorization.\"  id='checkbox_1_4dabf4c5f7d2332a0aede129db862ff5' aria-label='I understand that I have the right to receive a copy of this authorization.' aria-invalid='false' aria-required=true> <span> I understand that I have the right to receive a copy of this authorization.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_389d76d8306b5d97d02d63a177a47cf6'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\" I understand that any cancellation or modification must be in writing.\"  id='checkbox_1_389d76d8306b5d97d02d63a177a47cf6' aria-label='I understand that any cancellation or modification must be in writing.' aria-invalid='false' aria-required=true> <span> I understand that any cancellation or modification must be in writing.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_7ab01eb9bbaa4bebcdc4625c2d2a8244'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\" I understand that I can revoke this authorization at any time unless the provider has already relied on it.\"  id='checkbox_1_7ab01eb9bbaa4bebcdc4625c2d2a8244' aria-label='I understand that I can revoke this authorization at any time unless the provider has already relied on it.' aria-invalid='false' aria-required=true> <span> I understand that I can revoke this authorization at any time unless the provider has already relied on it.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_9c4dc18cd90d4588fa9a019749123a2f'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\" I understand that revocation must be submitted in writing  to Azizeh E. Rezayian, MA, LMFT.\"  id='checkbox_1_9c4dc18cd90d4588fa9a019749123a2f' aria-label='I understand that revocation must be submitted in writing  to Azizeh E. Rezayian, MA, LMFT.' aria-invalid='false' aria-required=true> <span> I understand that revocation must be submitted in writing  to Azizeh E. Rezayian, MA, LMFT.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_8230c700bce611196307a34e13362901'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\" I understand that signing this authorization is not a condition for treatment.\"  id='checkbox_1_8230c700bce611196307a34e13362901' aria-label='I understand that signing this authorization is not a condition for treatment.' aria-invalid='false' aria-required=true> <span> I understand that signing this authorization is not a condition for treatment.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_93ad863e9bf26650048ed91dfa703217'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\" I understand that disclosed information may no longer be protected under HIPAA, but may still be protected under State law.\"  id='checkbox_1_93ad863e9bf26650048ed91dfa703217' aria-label='I understand that disclosed information may no longer be protected under HIPAA, but may still be protected under State law.' aria-invalid='false' aria-required=true> <span> I understand that disclosed information may no longer be protected under HIPAA, but may still be protected under State law.<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-13_8\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h3>Patient Signature<\/h3><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_13_input_text_3' id='label_ff_13_input_text_3' aria-label=\"To sign this document, write your name in the field below.\">To sign this document, write your name in the field below.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_13_input_text_3\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_13_email' id='label_ff_13_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_13_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_13_datetime' id='label_ff_13_datetime' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_13_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\"  aria-label=\"Submit Form\">Submit Form<\/button><\/div><\/fieldset><\/form><div id='fluentform_13_errors' class='ff-errors-in-stack ff_form_instance_13_1 ff-form-loading_errors ff_form_instance_13_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_13_1 = {\"id\":\"13\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"asteriskPlacement\":\"asterisk-right\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_13_1\",\"form_id_selector\":\"fluentform_13\",\"rules\":{\"names[first_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[last_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_2\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"description\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"checkbox\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"checkbox_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_3\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"email\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"email\":{\"value\":true,\"message\":\"This field must contain a valid email\",\"global_message\":\"This field must contain a valid email\",\"global\":true}},\"datetime\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}}},\"debounce_time\":300};\n                            <\/script>\n                        <\/div>\n\n            \t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-71900913 elementor-widget elementor-widget-text-editor\" data-id=\"71900913\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>\u00a0<\/p>\n<h1 style=\"color: white;\">Limits of Confidentiality\/ Cancellation Policy<\/h1>\n<p>\u00a0<\/p>\n\n\n<p><\/p>\n\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":"<p>Authorization to Release Information Authorization to release information (Portland) AUTHORIZATION TO RELEASE INFORMATION This form allows you to give permission for Azizeh E, Rezayian, MA, LMFT, to share specific information from your mental health treatment with a person or organization you name. You are not required to sign this form. Signing is voluntary and will [&hellip;]<\/p>\n","protected":false},"author":34,"featured_media":0,"parent":14273,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-14317","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.2 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Confidentiality And Cancellation Policy<\/title>\n<meta name=\"description\" content=\"Authorize Azizeh F. Rezaiyan, MA, LMFT to share specific mental health information with a provider or organization. Submit your release form securely and confidentially online.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/cms-staginglink3.com\/aziza-client-site\/portland\/authorization-to-release-information-portland\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Confidentiality And Cancellation Policy\" \/>\n<meta property=\"og:description\" content=\"Authorize Azizeh F. Rezaiyan, MA, LMFT to share specific mental health information with a provider or organization. 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