This release is freely given and authorizes Dr. Davidson to request all my records and/or discuss me and/or my children verbally or in writing. The purpose for this request of records is legal rather than healthcare in order to complete a court ordered or court related psychological evaluation. I understand and agree that all information released with this authorization is NOT confidential. My signature indicates that ALL rights and privileges to confidentiality are waived.
I understand that this authorization extends to all of the records/information designated below which may include school/day care records, work records, medical records, behavioral health records including drug/alcohol abuse, HIV/AIDS test results or diagnosis, genetics, agency records, court and police documens. The information to be released includes the following:
[X ] Entire File AND/OR [X ] Interview or Questionnaire
This authorization is to be disclosed to Dr. James Davidson or his staff. I hereby release the Person or Entity releasing information from all legal responsibilities or liability that may arise from the release, use or disclosure of this information.
1. Expiration. I understand that unless I revoke this authorization earlier, this authorization will automatically expire in 180 days, or according to the relevant state or federal law, from the date this authorization is signed.
2. Re-Disclosure. I understand that information used or disclosed in accordance with this authorization may no longer be protected by HIPAA, and could be used or redisclosed by the receiving party. I further authorize redisclosure of any and all records protected by 42 CFR part 2.
3. Certification. I certify that I am the individual named in this release, or the individual's authorized representative, and that the identification and proof of authority that I have provided is true and correct.
4. Revocation. I understand that I may revoke this authorization at any time by notifying Dr, Davidson in writing at 800 W. Main St STE 1460, Boise, Idaho 83702. I understand that the revocation is only effective after it is received and logged by Dr. Davidson. I also understand that any use or disclosure made prior to the recovation under this authorization will not be affected by a revocation.
5. Copy. I understand that I am entitled to receive a copy of this completed form upon request.
6. Treatment. I understand that Dr. Davidson and Davidson Forensic Group will not condition treatment based on my signing this authorization. Further, I understand that no treatment is being provided since the purpose of this release is to obtain records per the order of the court.
7. Original. I understand that a photocopy, fax or pdf of this authorization is as valid as the original.
8. Signature. My signature on this form is signed by my hand on a computer. I hereby certify that the signature on this release is mine, and shall be used in lieu of my handwritten signature.
Signed (Please use your mouse or finger)