Authorization for Use or Disclosure of
Protected Health Information
Client Information
Clients Last Name : _____________________________________
First Name : _____________________________________
MI : _____________________________________
Client Address : _____________________________________
Client Home Phone : _____________________________________
Cell/Work Phone : _____________________________________
Client Email Address : _____________________________________
Recipient Information
I, _________________, do hereby authorize ________________ to release a copy of my mental health information to the person or facility below.
Name of person/facility to receive medical information: _________________________________________
Phone: ________________________________________
Address: ______________________________________________________________________________________
Date of Authorization: ___/___/___
Authorization to expire on ___/___/___ or upon the happening of the following event: ______________________________________________
Information to be Released (Note: Requests for release of psychotherapy notes cannot be combined with any other type of request.)
-
Mental health record
-
Only those portions pertaining to: ___________________________________________(Specific provider name and/or dates of treatment)
-
Authorization for Psychotherapy Notes ONLY (Important: If this authorization is for Psychotherapy
Notes, you must not use it as an authorization for any other type of protected health information.)
-
Other: ___________________________________________________________________________________________________________________
Purpose of Information Release:
Authorization and Signature
I authorize the release of my confidential protected health information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.
Signature of Patient: Date
_________________________
_________________________
If signed by a personal representative:
(a) Print your name: ___________________________________________________________________________________________
(b) Indicate your relationship to the client and/or reason and legal authority for signing: