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Release of Information

Release of Information

* denotes a required field

Authorization for Release of Information

Client Name *

Date of Birth *

I authorize the following provider:

[THIS PROVIDER]

[ADDRESS]

[PHONE]

[EMAIL]

[FAX]

To exchange information by: *

Sending

Receiving

The following types of information: *

Please select authorization of general information or disclosure of specific kinds of records.

Communication/disclosure of general information regarding client’s case for the purposes of coordinating healthcare services and providing the client with the best care.

Assessment

Diagnosis

Treatment Plan

Treatment summary

Medical history & physical/diagnosis/treatment

Educational/IEP/assessment

Family/social history

Progress/case notes

Psychological testing report

Termination/discharge info

Legal records

Financial/health insurance info

Other

To/from the following party:

Other Party Name *

Address *

Phone *

Email

FAX

This authorization expires in 1 year unless another length of time is entered here:

I understand my health information is protected by state and federal guidelines and cannot be released without my consent unless allowed by law. Only the information indicated above will be released exclusively between the entities listed above. I understand I can withdraw or modify this authorization at any time. My signature means I have read and understand this form.

I am: *

The client

Parent/legal guardian

Representative

Other

Signature *

By checking this, you are submitting your electronic signature.Write your text here...