Authorization to Request or Release Information

Authorization to Request or Release Information
Client's Name:
Client's Address (include street, city, state and zip code):
Date of Birth: (Month/Day/Year):

Month Day Year
Date
I, _______________________, authorize:

First Name Last Name
Hope for a Better Tomorrow
2607 N. Grandview Blvd, #110 Waukesha, WI 53188
Therapist Name:
To Disclose to and obtain information from:
(agency, organization, school, hospital, professional, etc.)
Address (include street, city, state and zip code):
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
The following information (check all that apply):

Medication Records Psychological Testing Report Initial Evaluation/Assessment Progress Notes Family Correspondence: Making/Checking appointments Family Correspondence: Progress update of client Treatment Plan Discharge Summary Billing and Payments
For the purpose of (specify):

Coordination of Care Effective Treatment Planning Diagnosis and Treatment
This authorization can be terminated at any time in writing. This authorization is valid for the duration of involvement, up to one year
Signature (Client 12 years of age and older) *

Clear
Date

Month Day Year
Date
Witness Initials

Clear
Signature (Parent or Legal Guardian)

Clear
Date

Month Day Year
Date
Witness Initials

Clear
Should be Empty: