Release of Information Form

Authorization to Use or Disclose Protected Health Information

(Required by the Health insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
Name

First Name Last Name
Birth Date

Month Day Year
Release Information to the Following
Name

First Name Last Name
Organization
Phone Number
By signing below, I am authorizing Kate Walker, LCSW to use and disclose my protected health information for the purposes of directing treatment and/or consultation or other purposes as I may direct

This authorization shall be in effect for one year from the date of the signature below unless otherwise expressed.

I understand I have the right to revoke this authorization, in writing, at any time.

I understand that my treatment will not be conditioned on whether I sign this authorization.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Signature of patient or personal representative

Clear
Printed name of patient or personal representative
Relationship to patient if applicable
Mother, Father, Guardian
Date

Month Day Year
Date
Should be Empty:

Authorization to Use or Disclose Protected Health Information