Client Authorization to Disclose Confidential Information

Client Authorization to Disclose Confidential Information
Client Name (person receiving treatment)

First NameLast Name
I authorize Total Health Concepts, LLC, to discuss confidential information regarding my treatment to (write name of doctor, psychiatrist, doctor, therapist, family member, etc.,):
Name of doctor, psychiatrist, therapist, family member, etc:
Relationship to client
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Address
In regard to:
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The purpose for this disclosure of information is to:
Disclosure of information is to be:
Expiration date for this authorization:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
This authorization is signed with the understanding that my records and treatment are confidential and will not otherwise be disclosed without my written consent unless under legal compulsion. Further, it is understood that I may withdraw this authorization in writing any time prior to the expiration date.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client signature
Parent/Guardian Signature
Phone Number

Area CodePhone Number
Should be Empty: