5891 Cedar Lake Road South, St. Louis Park, MN 55416
I hereby authorize my therapist (listed above) to exchange/release information and/or documents with the Authorized Individual named above for the purposes of providing appropriate mental health services. The specific information and/or documents include:
I have fully read and understand this Release of Information. I understand my records are protected by Federal Law (42 CFR Part 2) and cannot be disclosed without my permission as indicated by my signature below, unless otherwise provided in the Federal Regulations. I also understand I may revoke this release at any time prior to the information being exchanged. This Release of Information will automatically expire 365 days after date of signature. Form of DisclosureUnless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically. By e-signing you acknowledge your agreement with the information in this document.