Release of Information Form

Aubrey K. Ewing, Ph.D. & Associates, P.A.
1230 So. Federal Hwy., Boynton Beach, FL 33435
561.742-7122 | Fax 561.742.7452
Email: contact@drewingonline.com

PERMISSION TO RELEASE PROTECTED HEALTH INFORMATION
Patient/client name:
Date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security No.:
Email address for confirmation of receipt of this form
example@example.com
My signature on this form indicates that I give permission to Aubrey K. Ewing, Ph.D. & Associates, P.A. and the provider(s) named below to release my protected health information:
Please use this space to name the providers in the practice you are authorizing to release your protected health information
I authorize release of my protected health information to the following health care provider or other entity:
I grant permission for the following specific information to be released (check all that apply)::

Other
The purpose for this release/exchange of information is:

Other
I hereby release Aubrey K. Ewing, Ph.D. & Associates, P.A. and all others named above from any and all legal liability that may arise from the release of the identified protected health information. I understand that any disclosure is bound by Tile 42 of the Code Federal Regulations (chemical abuse/addiction clients), Florida Statues 294.459 (9b) and/or 90.53, 490, and 491 (psychiatric/psychological information), and the Health Insurance Portability and Accountability Act (HIPAA), and that re-disclosure of this information without my additional written authorization is prohibited.

I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance upon it. I certify that I have read the information above and that I understand and agree to its content.
Patient/client Signature
Witness Signature
Date

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