MH-ROI

Evergreen Youth & Family Services

Authorization to Receive or Disclose Confidential Information
I understand that records are protected under the law and may not be disclosed without written permission as provided by the law. Note: A separate authorization is needed for each individual and/or agency
Client Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
I authorize Evergreen Youth & Family Services to: *

Receive Information Disclose Information
Please enter below information regarding the individual or agency you are allowing Evergreen Youth & Family Services to share information with.
Individual or Agency: *
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Fax Number

Area Code Phone Number
This information is for (specify purpose):
This Information shall be limited to (check all that apply): *

Family/Social History Psychological/Psychiatric Evaluations/Reports Employment Records Medical Records Assessment/Treatment Treatment Summary Chemical Dependency Educational Records Diagnostic Assessment
I understand that I do not have to sign this authorization and that refusal will not affect my ability to receive services.

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken/ or received has been disclosed prior to my written revocation.

I also understand that once Evergreen Youth & Family Services Inc., has disclosed information I have authorized, Evergreen Youth & Family Services Inc., no longer has control over the information and the information might be re-disclosed by the person/agency authorized to receive this information.
This authorization automatically expires one year from the date of the signing or under the following conditions (specify):
Signature of Client *

Clear
Parent/Guardian if client is a minor

First Name Last Name
Signature of parent/guardian

Clear
Should be Empty:

Evergreen Youth & Family Services