Authorization for Release of Information

This form provides me with written permission to communicate with other individuals (example: psychiatrist, physician, previous therapist, attorney, naturopath, spouse, parent, etc.) regarding your treatment. Completing this form is voluntary and you may request to withdraw or modify releases of information at any time.

Today's Date *

Today's Date

YYYY

Client's Name *

Client's Name

First Name

Last Name

Client's Date of Birth *

Client's Date of Birth

YYYY

As a client in treatment with Mary Breen, L.C.S.W., hereby authorize her as my therapist to release and/or receive the health care information described below to and/or from the following individual: *

As a client in treatment with Mary Breen, L.C.S.W., hereby authorize her as my therapist to release and/or receive the health care information described below to and/or from the following individual:

Full name of individual (i.e. psychiatrist, medical doctor, family member, etc.) who will be receiving or releasing my health care information:

First Name

Last Name

Address of individual who will be receiving or releasing my health care information:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number of individual (i.e. psychiatrist, medical doctor, family member, etc.) who will be receiving or releasing my health care information: *

Phone number of individual (i.e. psychiatrist, medical doctor, family member, etc.) who will be receiving or releasing my health care information:

Country

(###)

###

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This request and authorization applies to the following Protected Health Information (PHI): *

My complete clinical record including but not limited to: intake information, treatment notes and recommendations, treatment plans, billing history, and administrative details.

My clinical record with the exception of the following information:

Describe

This request and authorization will remain in effect unless revoked or unless designated specifically here:

Date of Expiration

YYYY

I understand that, except for action already taken, I may revoke this authorization in writing at any time by delivering or sending written notification to Mary Breen, L.C.S.W. I also understand that I have a right to receive a copy of this authorization and that a copy will be maintained in my clinical record. I understand that I have a right to refuse to sign this authorization. The information disclosed pursuant to this authorization may be subjected to re-disclosure by the recipient and may no longer be protected by state and federal privacy laws. Recipient may not redisclose HIV-related information unless permitted to do so by special release. By marking the box below and submitting this form, I am electronically signing my name and authorizing the use or release of my Protected Health Information (PHI) for the reasons and the conditions established above. *

Client's Name *

Client's Name

First Name

Last Name

Name of Client's Personal Representative (Parent/Guardian)

Complete only if client is a minor.

First Name

Last Name