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:

MyselfMy minor child:
Child's Date of Birth

MonthDayYear
Date
The purpose for this disclosure of information is to:

Discuss treatment progressObtain medical records and/or progress notesRelease medical records and/or progress notesOther:
Disclosure of information is to be:

OngoingOne time only
Expiration date for this authorization:

MonthDayYear
Date
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
Date
Client signature

Clear
Parent/Guardian Signature

Clear
Phone Number

Area CodePhone Number
Should be Empty: