Foundations Counseling Services, Privacy Officer 28780 Single Oak Drive, Suite 217 Temecula, Ca. 92592 (951) 363-5255

Client’s Initials __________

With this consent, I give my permission for Foundations Counseling Services to:

Call my home or other alternative location and leave a message on voice mail,

answering machine, Texting, or in person, in reference to any information that assists the

practice in carrying out treatment, payment, and healthcare operations to include, but not limited

to appointment reminders, insurance concerns/questions, and calls pertaining to my care.

[ ] Mail to my home or other alternative location any information that assists the practice in

carrying out treatment, payment, or healthcare operations.

[ ] Release or communicate information by telephone, E-mail, Texting or in writing, any

information that assists the practice in carrying out treatment, payment, or healthcare

information with my spouse, family member or other representative that I have indicated

below:

(IF A FIRST NAME, LAST NAME, AND RELATIONSHIP TO THE PATIENT IS NOT

LISTED, ONLY THE PATIENT CAN ACCESS HIS/HER RECORDS. IF YOU LIKE US TO

CONTACT YOU THROUGH EMAIL / TEXTING PLEASE LIST YOUR EMAIL CELL

NUMBER).

PATIENT’S Email:

I have the right to request that Foundations Counseling Services restrict how it uses of discloses my protected healthcare information to car out treatment, payment, and or healthcare operations. I may revoke my consent in writing, except to the extent that the practice has already made discloses in reliance upon my prior consent. If I do not sign the consent or late revoke it Foundations counseling may decline to provide me treatment.

Client’s Name: ________________________________________________________________ Date:_________________________________

Signature: _______________________________________ Date of Birth: _________________________________