Auth to Release/Obtain E-Form

Auth to Release/Obtain Info
Please use the following for correspondnece:

HH @ Lake Ivanhoe Village

1199 N Orange Ave Orlanfo, FL 32804

| admin@hhorlando.com | Main: 407-701-4500 | Fax: 407-270-5900 |
Client Name*

First NameLast Name
The following person(s) and/or organization(s) are authorized to release and/or obtain the administrative & clinical records specified below:
Name (Person / Organization)*
Recipient or Destination
Relationship to Client*
Person / Organization Phone Number*

Area CodePhone Number
Additional Info re: Person(s) / Organization(s) *
Physical Mailing/Billing Address, Preferred Email/Fax/Web, etc
Comments / Notes
Include Any Additional Designees Here (Secondary Contact)
HH Retrieving Medical Records & Relevant Information

The Healing House is authorized to obtain record(s) from those included above
Check all that apply for the following record(s) to be released and/or obtained:*

Demographics/AdministrativeGeneral Clinical or MedicalMental Health/PsychiatricLabs/Drug ScreeningsInsurance/FinancialsAll of the AboveOther
Client or Guardian Signature*

Clear
Should be Empty:

Auth to Release/Obtain Info