AUTHORIZATION FOR RELEASE OF INFORMATION

Karin Elise Weber, LCSW Mental Health Services
1936 William Street Fredericksburg, VA 22401

Phone: (540)455-4715 Fax: (540)371-5715

Website: http://www.kweberlcsw.com Email: karin@kweberlcsw.com
Authorization for Release of Information
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
I hereby authorize the communication of clinical information between Karin Elise Weber, LCSW, PLLC and the following individuals.

Please initial, date, and mark all that apply.

Note: Parent/legal guardian to initial if the client is a minor.
Primary Care Physician
Initial Here (if you would like to release information to Primary Care Physician)
Primary Care Physician, Release Date

MonthDayYear
Primary Care Physician, Name

First NameLast Name
Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician Phone
Please enter PCP primary office phone number.
Primary Care Physician Email
example@example.com
Psychiatrist
Initial Here (if you would like to release information to Psychiatrist)
Psychiatrist, Release Date

MonthDayYear
Psychiatrist, Name

First NameLast Name
Psychiatrist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Psychiatrist Phone
Please enter your psychiatrist's office phone number.
Psychiatrist Email
example@example.com
Teacher/School
Initial Here (if you would like to release information to Teacher/School)
Teacher/School, Release Date

MonthDayYear
Teacher/School, Name

First NameLast Name
Teacher/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Teacher/School Phone
Please enter the teacher/school office number.
Teacher/School Email
example@example.com
Other
Initial Here (if you would like to release information to Other)
Other, Release Date

MonthDayYear
Relationship of Other to Client
Other, Name

First NameLast Name
Other, Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other, Phone
Type the primary phone number for this individual.
Other, Email
example@example.com
Communication may include direct verbal communication, clinical documentation including inpatient and outpatient treatment notes, discharge summaries, testing and laboratory results, and similar clinically relevant materials. I understand that I may withdraw this consent at any time by submitting a request in writing. Please note that once the requested information is disclosed pursuant to this Authorization, Karin Elise Weber, LCSW, PLLC will no longer have control over the information and there is a potential that it may be re-disclosed by the recipient and will no longer be protected by the privacy rules under the Health Insurance Portability and Accountability Act.
Client Signature (Note: Parent/Legal Guardian to sign if client is a minor)*

Clear
Full Name of Signee (above) (Client or Parent/Legal Guardian is client is a minor)*

First NameLast Name
Date Signed*

MonthDayYear
** This authorization for release of information is good for one year after date signed, until client (or parent/legal guardian if client is a minor) revokes authorization, or until client (or parent/legal guardian if client is a minor) is discharged from treatment (whichever precedes).
Please verify this item.*
Should be Empty:

Karin Elise Weber, LCSW Mental Health Services

Authorization for Release of Information

Primary Care Physician

Psychiatrist

Teacher/School

Other