HIPAA Authorization Form

Mutts With A Mission
2700 Shirley Landing Drive, Virginia Beach, VA 23457
(757)465-1033  |  Fax: (757)465-1088
apply@muttswithamission.org
www.muttswithamission.org

Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)





Name of the healthcare provider authorized to use and disclose your protected health information.

I hereby authorize the above-named healthcare provider to use and disclose the protected health information related to my complete health records; including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse; to Mutts With A Mission (MWAM) for the purpose of applying, placement, and/or recertification of a Service Dog.


I understand that I may inspect or copy the protected health information described by this authorization.


I understand that, at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my healthcare and the payment for my healthcare will not be affected if I refuse to sign this form.


I understand that information used or disclosed, pursuant to this authorization, could be subject to redisclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.




This authorization will expire on this date or event. If left blank, the expiration date will be six years from the date of this authorization.

COPY PROVIDED: A copy of this authorization can be requested for your records when signed. 

Primary Behavioral Health Questionnaire

Primary Behavioral Health Questionnaire

To be completed by LCSW, LISW, LPC, PSYCHOLOGIST, or PSYCHIATRIST

Applicants: Please sign and date this form prior to giving it to your healthcare professional. Primary Mental Health providers should complete and return directly to Mutts With A Mission.

Physician's Release




Therapist's Contact Information







Questionnaire Section (To be completed by therapist)













































Contact Information