Release of Information Form

Release of Information

Authorization to Use/Disclose Confidential Protected Health Information
If you would like someone or an agency to communicate with your clinician about you or your child's evaluation or treatment, please complete the following form.
Date*

MonthDayYear
Date
Which clinician are you authorizing with this form? *
Regarding (Client Name)*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Who is completing this authorization form?*

The clientLegal guardian or parent for the client
Your name (if not the client)

First NameLast Name
Name of the program/court/agency/person authorized to receive/disclose/exchange Information*
(i.e., such as another doctor, practice, agency, school, DFCS, etc.)
Contact information
(i.e., phone number, email address, mailing address)
The method of communication can include any appropriate method (encrypted email, verbal - in person or via phone, US mail, fax) unless otherwise specified to your clinician.
Purpose of disclosure*

Completing a Psychological Evaluation or AssessmentEngaging in Psychotherapy or CounselingTreatment PlanningOther
Information to be disclosed (check all that apply)*

All client records and information (no exclusions)Client mental health information and/or general medical informationClient alcohol/drug treatment informationHIV-related information for the client (if applicable)Any records that have been obtained by my clinician from other providers or source.Other
Affirmation of Release By signing and completing this form, I give the above-identified clinician permission to release only the information I have selected on this form to the individual or agency I have named and only for the purposes designated. I understand that I may refuse to sign this authorization. I also may revoke this authorization at any time in writing, and it will take effect on the day it is received. Any revocation or refusal to sign this authorization will not affect my ability to obtain treatment or payment or my eligibility for benefits. As a patient, I have the right to access my treatment records as allowed by HIPAA. Copies of the records may be obtained with reasonable notice and payment of copying costs. I understand that if the person or entity that receives the above-specified information is not a health care provider or healthcare entity covered by federal privacy regulations or a business associate of these entities, the information released may be re-disclosed and no longer protected by the regulations and Privacy Rule.
Release Expiration Date*

MonthDayYear
This release can only be valid for up to one year from now.
Client Signature (for adults) or Legal Guardian/Parent Signature (for children)*

Clear
Should be Empty: