AUTHORIZATION TO RELEASE/RECEIVE INFORMATION

AUTHORIZATION TO RELEASE/RECEIVE INFORMATION
120 East Trinity Place | Decatur, GA 30030 | Phone (404) 378-2300 | Fax (404) 378-2394
CLIENT INFORMATION

(Confirm correct name spelling and DOB with client and/or guardian)
Name*

First NameMiddle InitialLast Name
DOB*
This document authorizes Pathways Transition Programs, Inc. (PTP) to release and/or receive in writing or through telephone contact psychological, psychiatric, and general medical records including substance misuse or addiction information. Information will be shared, following Georgia State Statues and Federal Administrative Rules and Regulations, with:
INDIVIDUAL OR AGENCY
Name*
Address*
Phone*
Email Address*
example@example.com
Fax
MEDICAL RECORD
PTP can RELEASE this info to the individual or agency listed above:
Medical Histories & Physicals*

AllSelection Below
Medical Histories & Physicals*

Drug Screen ResultsAssessmentsPsychological TestingPsychiatric TestingCase SummaryDischarge SummaryProgress NotesTreatment PlanSchool RecordsOther
PTP can RECEIVE this info from the individual or agency listed above:
Medical Histories & Physicals*

AllSelection Below
Medical Histories & Physicals*

Drug Screen ResultsAssessmentsPsychological TestingPsychiatric TestingCase SummaryDischarge SummaryProgress NotesTreatment PlanSchool RecordsOther
PURPOSE OF RELEASE?
Records released for?*

Continued TreatmentCase PlanningOne TimeOne YearOther
RELEASE DURATION
Records released for how long?*

One-TimeOne YearOther
Continuous until*
If this release is for court ordered psychological evaluation, the evaluation will be used as evidence in court. It will be released to the referring agency or attorney; you may request information from that agency or attorney. Your consent can be withdrawn at any time, but we cannot recall information we have already shared in order to comply with your consent.
Redistribution of Confidential Information is Prohibited
Disclosed information is protected by Federal Rules governing confidentiality rules (42 CFR part 2 The Federal Rules prohibit recipients from making any further disclosure of this information unless the subject of the material provides additional written permission (42 CFR Part 2 This general authorization for the release of medical or other information is not sufficient for this purpose. Also, Federal Rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.

INTAKE6-ENG–AUTHORIZATION RELEASE/RECEIVE INFORMATION Revised 1/28/2022
Name*

First NameMiddle InitialLast Name
DOB*
I am an adult, over 18 years of age; I am the client*
The client is a minor; I am the client’s parent*
The client is a minor; I am the client’s legal guardian*
Other*
I understand all information contained in this document. I had the opportunity to ask questions and they have been answered. I voluntarily authorize the information specified above to be obtained from or released to PTP; it will be held in strict confidence. I understand my information cannot be re-released by a recipient without my written consent. I understand this authorization will remain in effect until I specify an expiration date. If I have questions concerning any of this content in the future, I will ask my clinician. I release PTP from any legal responsibility that may arise from the release of the above requested information.
Client/Parent/Guardian Signature*

Clear
Print Name*
Date*

MonthDayYear
Date
PTP Representative Signature & Credentials*

Clear
Print Name & Title*
Date*

MonthDayYear
Date
INTAKE6-ENG–AUTHORIZATION RELEASE/RECEIVE INFORMATION 1/28/2022
Should be Empty:

AUTHORIZATION TO RELEASE/RECEIVE INFORMATION

INDIVIDUAL OR AGENCY

MEDICAL RECORD

PTP can RELEASE this info to the individual or agency listed above:

PTP can RECEIVE this info from the individual or agency listed above:

PURPOSE OF RELEASE?

RELEASE DURATION

Redistribution of Confidential Information is Prohibited