Exchange/Release Psych Form

AUTHORIZATION TO RELEASE/EXCHANGE CONFIDENTIAL INFORMATION
By completing this form, I attest that I am the client named below or I am the parent/legal guardian of the client named below. I am completing this form to allow the use and sharing of HIPAA/FERPA protected health information with Kimi Walker, School Psychologist about:
Parent/Guardian/Adult Clients's Full Name:

First NameLast Name
Child/Minor's Full Name (If Applicable)

First NameLast Name
Date of Birth (Child/Minor or Adult Client's Date of Birth)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I here by authorize Kimi Walker, School Psychologist to (select all that apply):
Name (Person or Organization)
e.g., Dr. Jane Smith or Indiana University Health Records
Address
Paste or type the full address, including city, state, and zip
Phone Number
Include area code
Fax Number
Include area code (if applicable)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Relationship to Client (e.g., medical provider, university, etc.)
The following information pertaining to myself and/or my child:

Other
for the purpose of:

Other
This consent will automatically expire one (1) year after the date of my signature as it appears below, or on the following earlier date, condition, or event
(please specify or write “N/A”).
I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the information has already been released).
First Last Name of Person Completing this Form

First NameLast Name
Phone Number of Person Completing this Form

Area CodePhone Number
Phone Number of Person Completing this Form
Include area code
Email of Person Completing this Form
example@example.com
Signature of Person Completing this Form
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

AUTHORIZATION TO RELEASE/EXCHANGE CONFIDENTIAL INFORMATION