Release of Information

Authorization for the disclosure of protected health information.

Name*
First Last
Date*
MM slash DD slash YYYY
Email*
Date of Birth*
MM slash DD slash YYYY
I authorize the disclosure of information related to my treatment to and/or obtain from:*
Please list all of the institutions and/or individuals with whom you are authorizing us to communicate, including designated titles.
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relevant Information to be Provided/Received may include:*
This information is to be used for the purpose of:*
Consent
I agree to and fully understand the following:
• I understand that I have the right to revoke this authorization, in writing, at any time. However, my revocation will not be effective to the extent that any action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

• I understand that my clinician 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 redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.
This authorization to release information will be effective for twelve months. If a shorter time period is desired, please indicate the date on which this authorization will become null and void:
MM slash DD slash YYYY
Signature
Date
MM slash DD slash YYYY