AUTHORIZATION FOR RELEASE OF RECORDS

I hereby authorize (Name of Doctor, Physician, Facility, Program):*

to release to CLAYS any and all medical, confidential, employment or other information requested regarding the above named individual which it has in its possession.

NAME:*

First NameLast Name

SS#:*

DOB:*

Date

The disclosure is to be used for:

I understand that if the organization authorized to receive information is not a health plan or health care provider and if such information is re-disclosed by the recipient, the released information may no longer be protected by federal privacy regulations, but may be protected under Maryland State Law.

I understand that this authorization is voluntary.

I understand that the client’s health care and payment will not be affected if I do not sign this form.

I understand that I may receive a copy of this form after I sign it and that I may inspect and request a copy of the information I am authorizing for use or disclosure.

I understand that these records are to be kept confidential and the information is for use by that action has been taken in reliance upon it.

I understand and agree that this release may contain information pertaining to psychiatric, drug and/or alcohol diagnosis and treatment.

I understand that I may revoke my consent in writing at any time, except to the extent that an action has been taken in reliance upon it.

Authorized Signature*

Relationship to Minor (if applicable)

Date*

Date

This release will expired one (1) year from the date hereof unless otherwise noted.