Wavelength Release of Information

AUTHORIZATION TO RELEASE OR OBTAIN PROTECTED HEALTH INFORMATION

This form is to be completed and signed by client or parent/guardian, if client is a minor. A signed form authorizes the release of, or obtainment of requested protected health information from your clinical record to an individual or facility.
I, First Name Last Name hereby authorize and give permission to Wavelength Psychotherapy, LLC (hereinafter "Provider) to from third-party, blank . I First Name Last Name understand that the medical record may contain information concerning me or my child's psychiatric, psychological, drug or alcohol abuse, sexual abuse treatment, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions, and that under law these records are classified as privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an expressed and informed consent. In addition, I First Name Last Name understand that those records will not be released to entities other than those designated by myself or my personal representative or otherwise provided in federal law.
INDIVIDUAL OR AGENCY INFORMATION
Type of Agency
Contact Person
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I authorize "Provider" to release, discuss, disclose and/or request (from third-party indicated above) the following Protected Health Information (PHI) (Please check each applicable item):

Assessments and/or Biopsychosocial EvaluationAcademic RecordsCourt DocumentsDischarge/Transfer SummaryFinancial RecordsLetter(s) of ProgressMedical Health RecordsProcess NotesProgress NotesPsychiatric EvaluationsPsychological EvaluationsRecommendations for TreatmentVerbal Communication(s)Other
Client Signature*

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By signing, I agree to the terms of this Print Release.
Date

MonthDayYear
Date
This authorization will expire when the client is discharged from the current episode of care, treatment has been completed, the client rejects, declines and/or discontinues treatment and contact, is referred elsewhere, moves, or in the case of the client's death. This authorization may be canceled in writing at any time and that refusal to sign will not affect treatment.
Wavelength Psychotherapy, LLC

hello@wavelengthpsychotherapy.com
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AUTHORIZATION TO RELEASE OR OBTAIN PROTECTED HEALTH INFORMATION

Wavelength Psychotherapy, LLC