Release of Information

Release of Information
Thereby authorize Healing Solutions, Dr Cayce Paddock, Connie Guthrie and/or Terri Williams-Glass, to release and receive Personal Health Information (PHI) to/from:
Name*

First NameLast Name
Address*
Telephone*
Please enter a valid phone number.
The information requested or authorized for release or exchange pertains to:*

Mental HealthDrug or alcohol abuseEducationOther
This authorization is valid for 365 days from the date below. I may cancel this authorization by signing, dating, and writing "cancel" on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel. I understand that once my information has been released, the recipient might re disclose it, my doctor or therapist has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my mental health evaluation or treatment.
Patient's Name*
Date of Birth*

MonthDayYear
Date
Patient's Signature*

Clear
Today's Date*

MonthDayYear
Date
Guardian's Signature (if patient is a minor)

Clear
Today's Date

MonthDayYear
Date
Should be Empty: