WCP Authorization to Release Information and Records

Authorization to Release Information and Records

Note: Complete one form per person/agency you are authorizing WCP to communicate with
Client's Name (i.e., person receiving services)*
Client's Birth Date*

MonthDayYear
I, First Name* Last Name* , hereby authorize the following professional person/agency (i.e., the name of the person/agency you are permitting WCP to communicate with):
Professional Person/Agency Name (i.e., the name of the person/agency you are authorizing WCP to communicate with)*
If you are permitting WCP to communicate with your child's school, please write in the school name here.
Are you currently completing this form to provide authorization for WCP to communicate with professionals at your child's school (e.g., teachers, social workers, learning specialists, etc.)?*

YesNo
List the specific school professionals' names that WCP is seeking to communicate with, including their email addresses and phone numbers (if relevant) (separate entries by commas)*
School Address*
Professional Person/Agency Address*
Professional Person/Agency Phone Number*
Professional Person/Agency Email Address*
The Professional Person/Agency/School is authorized to (select one or more)*

obtain copies of my records from Wolff Child Psychologyexchange reciprocal information with Wolff Child Psychology (e.g., verbal discussion between the professional and WCP staff)
Do you permit this Authorization to include all of the client's records?*

YesNo
Specify which records this Authorization extends to:*
The purpose for which the information is to be used (select all that apply):*

Supporting the evaluation process.Coordination of care.Other (please specify)
Please specify the purpose for which the information is to be used:*
If requesting use or disclosure of psychotherapy notes, select yes. If this is not applicable to you, select no.*

YesNo
Please review and initial each of the following:
I may revoke this authorization at any time except to the extent that action has already been taken to comply with it. To revoke this Authorization, I need to send a written request to: Brian Wolff, Wolff Child Psychology, 3345 W. 38th Avenue, Denver, 80211*
Initials
This Authorization will expire in one calendar year from the date of signature with Wolff Child Psychology, unless I specify an earlier date below. The Authorization must be renewed at least annually to remain valid.*
Initials
Select yes if you would like to set an expiration date in less than one calendar year.*

YesNo
Expiration date for this authorization, if earlier than one calendar year*

MonthDayYear
Information used or disclosed pursuant to this Authorization may be re-disclosed by the recipient and no longer subject to HIPAA.*
Initials
I have the right to receive a copy of this Authorization.*
Initials
Wolff Child Psychology may not condition treatment on whether I sign this Authorization.*
Initials
I hereby release Wolff Child Psychology, from any liability, which may result from furnishing the information requested as authorized by this release.
Client's Name*
Client or Responsible Party's Signature #1*

Clear
Date*

MonthDayYear
Name and Relationship to Client of Responsible Party #1 *
Client or Responsible Party's Signature #2

Clear
Date

MonthDayYear
Name and Relationship to Client of Responsible Party #2
Would you like a copy of this form for your records?*

YesNo
Enter the e-mail address where you would like the copy of this form sent:*
Should be Empty: