Release of Information

I hearby authorize the therapist listed below:

(Enter your provider's name.)

I authorize this release of information concerning:

(Please enter your name or the client's name above.)

I authorize the following individual to receive/release/exchange information with provider listed above:

(Enter the individual's name here that your provider can contact.)

If you selected "Other" above, then please describe here:

This consent is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance herein, and, if not earlier revoked, it shall terminate at one year from the date of this document without revocation.

I understand that disclosures may not be subject to confidentiality if the therapist becomes aware of any suicidal or homicidal thoughts or plans, or in the event that the therapist becomes aware of any form of abuse or neglect.

I understand that my psychologist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.

I have read, or had read to me, the above, and understand the contents.

I authorize this information to be sent to the party indicated above by one or more of the following means, and understand the limits of confidentiality which doing so creates.

(Enter your INITIALS here.)

Please select ALL that apply.

Fax

Text

Phone

Client's Signature (Or parent/guardian's signature if client is under 18 years of age.)

By typing your name above, you are signing this release of information form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this release of information.

Your information will be encrypted.