AUTHORIZATION FOR RELEASE OF INFORMATION
Jan Beauregard, Ph.D., LPC, CSAC, CSAT, LLC
3615 Chain Bridge Rd. Unit I (Eye) Fairfax, VA 22030
Authorization to Release (Disclose) Protected Health Information
I hereby authorize:
Name of physician, provider or person disclosing the information: _________________
Address________________________________________________________________
City ___________________________
Phone Fax Email ______________________________________________________
to release OR to reciprocally release copies of the confidential information
described below, which may include alcohol and substance abuse information and/or
abstract information, this includes medical, psychiatric and/or psychological information
that may be protected under HIPAA.
Name of Client: ________________________________________ DOB: ___________
Client's/Patient's address: ___________________________________________
_________________________________________________________________
TO: Jan Beauregard, Ph.D., CSAC, CSAT, LLC

PURPOSE FOR RELEASE:
Coordination/Continuity of Care
Personal * Legal Matter*
Other*: ________________________ * - May incur a fee for copies
I specifically authorize release of the following information:
Medical History/Intake Evaluation Consultation Reports or Notes 
Progress Notes
Verbal Discussion of Case Substance Abuse Treatment Notes
Other:_____________
The requested records or information is about health care provided during the
approximate time frame below starting with the first treatment date through the
expiration of this release of information on the following date:
from _____/_____/_____ to two (2) weeks post discontinuation of therapy

CLIENT RIGHTS AND INFORMATION
COPY FEE: I understand that there may be a copy fee for release requests for personal,
legal, or other use. I understand that in compliance with Va. Code Section 8.01-413
(2003), I will pay a fee of $0.50 per page to cover preparation costs of the records.
RELEASE FROM REDISCLOSURE: I understand that protected health information
disclosed pursuant to this authorization may be re-disclosed by the recipient(s) to other
individuals or organizations that are not subject to privacy protection laws. I also hereby
release Jan Beauregard, Ph.D., LLC, its officers, and therapists from all legal
responsibilities and liabilities that may arise from the release of such protected health
information. NOTE: The receiving party is prohibited from re-release of substance abuse
information without client's/patient's consent.
REVOCATION: I may revoke this authorization at any time, by written notice to Jan
Beauregard, Ph.D., LLC, except to the extent that action has already been taken to
comply with it and that the written revocation is effective upon receipt. Without my
express revocation, the authorization will automatically expire: (1) upon satisfaction of
the need for disclosure; (2) on ____/_____/____ [date supplied by Client/Patient]; (3)
under the following condition(s):
_______________________________________________________________________
If no date or condition is indicated, this Authorization will expire two (2) weeks post
discontinuation of therapy.
RECORDS USE: I understand that the information will only be used for the development
of/continued therapeutic treatment and no one other than the above parties may have
access.
CLIENT COPY: I understand that I am entitled to request a copy of this Authorization.
AUTHORIZATION:
I understand that my refusal to sign this Authorization will not jeopardize my right to
obtain present or future treatment except where disclosure of the information is
necessary for the treatment. I certify that this request is made freely, voluntarily and
without coercion and that the information given above is accurate and complete to the
best of my knowledge. I have carefully read and understand the above, and do herein
expressly and voluntarily authorize disclosure of the protected information.
Signature of Client/Patient Date
If client/patient is a minor age 13-17, signature is required. Also, when client/patient
is a minor, or is not competent to give consent, the signature of a parent, guardian, or
other legal/authorized representative is required.
Print Name of Client/Patient
Parent, Guardian, or Authorized Representative Signature Date
Print Name of Parent, Guardian, or Authorized Representative
Relationship
Witness Statement/Signature: I have witnessed the execution of this authorization
and state that a copy of the signed authorization was provided to the client/patient and/or
his/her authorized representative.
Witness Signature
Date
______________________________________________________
_________
______________________________________________________
_________