Authorization for Release of Information

Please correct the errors described below.

Client's Full Name

Date of Birth

Information to be released:

Summary of Treatment to-date

Report

Other

If other, Explain

Purpose of Disclosure

Coordination of Care

Other

If other, Explain

Persons authorized to make Disclosure:

Persons authorized to receive Disclosure

Method of Disclosure

Written

Verbal

Electronic

Authorization to Begin

Authorization to Expire

I understand that my health information is protected by law. I authorize the release of my confidential health information as indicated above. I understand that my consent is voluntary and I can revoke this permission at any time, except to the extent that it has already been shared based on this authorization. Should I choose to revoke this authorization I will state this in writing.

By checking this box, I have read, understood, and agree to the above.

Signature of Patient

By checking this box, I have read, understood, and agree to the above and declare I am a personal representative of the patient above.

Signature of Personal Representative

Date

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Electronic signature

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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