Release of Information Form

Authorization for Release or Exchange of Protected Health Information (PHI)
Patient's Name *

First Name Last Name
Patient's Birth Date *

Month Day Year
Email *
example@example.com
Provider's Name *
I authorize my provider, {providersName} and/or his or her administrative and/or clinical staff to release and/or exchange the following information in regards Mental Health Records:
Please Choose All that Apply: *

Copy of file or chart Diagnosis/Diagnostic Impressions Testing/Assessment Results Prognosis/Impressions/Recommendations Treatment Plan Psychotherapy Notes or Mental Health Records Other (Provide description of the information that you want disclosed. Your description should be as specific and detailed as possible.) Billing Information including invoices, dates of service and diagnostic information as needed.
This information should be released to , received from and/or exchanged with:
Name of Person or Company: *
Phone Number of Company or Person *

Area Code Phone Number
Fax Number of Company or Person (if applicable)

Area Code Phone Number
Address Company or Person (if applicable)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email of Company or Person
example@example.com
I am requesting my provider to release/receive/exchange this information for the following reason(s): *
This authorization shall remain in effect until the following date: *

Month Day Year
Date
You have the right to revoke this authorization, in writing, at any time by sending such written notification to our office address. However, your revocation will not be effective to the extent that we have taken action in reliance on the authorization of if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Patient Privacy Rule.
Signature of Patient or Legal Guardian *

Clear
Name of Person Signing this Form: *

First Name Last Name
Date of Signature *

Month Day Year
Date
Should be Empty:

Authorization for Release or Exchange of Protected Health Information (PHI)