Authorization for Release of Medical Records

Name of Client (First, Last)

Name of Person Completing Form (if different than client)

Relationship to Client (if person completing form is not client)

Email address

Last four digits of SSN of client:

Type of Information to be released (List as specifically as possible, for example: dates of service, psychotherapy notes, diagnoses, etc).

Purpose for Information Release (List as specifically as possible, for example: to receive benefits, for legal action).

Release Information to the Following:

Name (First, Last)

Phone Number

Email address

Records are being requested for the following purpose:

Continued medical care

Legal Purposes

Insurance Purposes

Personal Interest

Other

Where records should be sent (if being mailed): Street Address, City, State/Province, Postal/Zip Code

Release Date Expiration (recommendation is one year past today's date but cannot be longer than two years past today's date)

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing

I understand that there is no charge for my records to be sent electronically by secure email. However, I will be charged $15 for the first 10 pages and $.50 for each additional page if I request that my records be mailed to me or to someone else.

I understand that if I choose to have my records sent electronically via encrypted email, there is a risk that electronic communications may be compromised, unsecured, and/or accessed by a third party despite Ignite sending such records in a secure and encrypted format. If I chose this format, I acknowledge those associated risks.

I understand that if I choose to have my records sent via USPS, there is a risk that paper mailed communications may be compromised, unsecured, and/or accessed by a third party. If I chose this format, I acknowledge those associated risks.

E-Signature: Type in your First and Last Name. I agree that my signature on this document (hereafter referred to as your "E-Signature") is as valid as if I signed the document in writing.

Your information will be encrypted.