Release of Information Disclosure Form Rev. September 2022

Release of Information Disclosure Statement

Please fill in the form below
Today's Date*

MonthDayYear
Date
Client Legal Name*

First NameMiddle NameLast NameSuffix
Client Date of Birth*

MonthDayYear
Provider to release information: *
Information to be disclosed:*

Clinical Case NotesTreatment SummaryPsychological Testing ReportsBilling SummaryOther
Who would you like information released to?*

Self / Client GuardianAnother Facility / individual
Name of individual or facility to receive information:
Doctor Name, Facility Name, Lawyer Name, etc.
Fax Number of person/facility to receive information:

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like information to be disclosed?*

E-MailFaxIn person
E-Mail Address: *
Fax Number: *

Area CodePhone Number
Purpose or need for disclosure*
Enter the purpose or need for the disclosure
Name of individual filling out form: *
Relationship to client if not self:
Guardian, enter your relationship to the client
Please attach a picture of your Photo I.D.: *

Browse Files

Cancelof
Disclosure Expiration (Please list an expiration for disclosure. If no date is entered, this disclosure will expire in one year from date of completion):

MonthDayYear
Enter the date the consent expires if sooner than one year.
You may revoke this consent to disclose the above-stated information by notifying the clinician disclosing the information and the person faxing/sending the information that you no longer desire to have your health information disclosed. You may contact these individuals by calling our office or sending them a written notice of your desire to no longer have your health information released.

Please mail your written notice to:

Pattison Professional Counseling & Mediation Center
259 E Oakdale Avenue, Crestview, Fl. 32539 | 850-682-1234
7 Vine Avenue NE, Ft. Walton Beach, Fl. 32548 | 850-863-2873
Signature of Client / Client Guardian*

Sign this document agreeing to the disclosure of the information Clear
Should be Empty:

Release of Information Disclosure Statement