Authorization for Release of Information

Authorization for Release of Information
Client Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
I hereby authorize JUST BREATHE CONNECTICUT LLC to release information to / obtain information from : *
Organization / Person
Phone Number *
Please enter a valid phone number.
Organization / Person Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Purpose of Disclosure- Select one *

Continuity of Care Collateral Coordination Client Request
Information to be Disclosed *

Attendance Diagnosis Assessment / Evaluation Treatment Plan Treatment Summary Other (specify below)
Dates of Treatment Covered by this Release *

All episodes of care Other (limited to the following dates)
I understand that I may revoke this authorization at any time in writing, and it will be effective on the date of organization notification except to the extent action has already been taken in reliance upon it. I understand that, unless revoked, this authorization will be valid for one year after signature. I understand that information to be released or obtained may include mental health, medical, substance abuse or HIV/AIDS-related information.
Signature *
Date signed *

Month Day Year
Date
Signed By *

Client Guardian
Just Breathe Connecticut LLC 4 West Road PO Box 566 Ellington CT 06029
Should be Empty:

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