Release of Information/Authorization

Kim Chupurdia, PhD. PO Box 2808, Spokane, WA 99220 910 W. 5th, Ste. 600, Spokane, WA 99204

Release of Information/Authorization Deposition Form

Patient Name: ______Date of Birth: ______

I. My Authorization

Check whether information should be Received (From) and/or Released (To) (Checking BOTH “from” and “to” will allow for two-way communication between the parties)

 From  To  From  To

Kim Chupurdia, Ph.D. ______Columbia Medical Associates ______910 W. 5th Avenue, Suite 600 ______Spokane, WA 99204 ______Phone: (509) 688-6700 Phone: ______Fax: (509) 455-6913 Fax: ______

Check the purpose for releasing this information

 At my request  Deposition  Subpoena

Check the type of information you would like to authorize (Check all that apply)

 All mental health/medical information including psychotherapy notes  Mental health information relevant to the deposition only. What information is relevant is to be determined by Dr. Chupurdia and discussed previously with the patient.

Check the expiration of the release

This authorization ends 90 days from the date signed.

II. My Rights

 I understand that I have the right to revoke this authorization at any time by giving written notice to Columbia Medical Associates. However, I understand that prior to revoking it information may already have been released as a result of this authorization.  I understand that the information released may be re-released by the recipient and is no longer protected by the HIPAA privacy rule  I understand that Columbia Medical Associates may not condition psychological services upon my signing an authorization unless the psychological services provided to me are for the purpose of creating health information for a third party or to take part in a research study.  Dr. Chupurdia has discussed the limitations of this release. I understand what information she considers relevant to this deposition and agree with her decisions in this regard.

Signature of Responsible Party: ______Date: ______Gibbs, Gordon Page 2 Relationship to Responsible Party (e.g. self, parent): ______

Witness: ______Date: ______