AUTHORIZATION TO OBTAIN AND RELEASE INFORMATION

AUTHORIZATION TO OBTAIN AND RELEASE INFORMATION
In order to provide the best care possible, Dr. Seth Dorsky and providers need to gather and share information with other individuals and organizations. This occurs through both verbal and written communication, including emails, faxes, and written reports. This form is intended to authorize Dr. Dorsky and providers to gather and share information with other individuals and organizations. Please include the patient’s primary care physician and school information under “Individual(s)/Organization(s) to share information with.”
Information Will Be Shared About:
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Individual(s)/Organization(s) to share info with:

(Please note that a copy of this completed form will be shared with those listed below:)
Disclose ToRequest From
Primary Care Provider:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Disclose ToRequest From
School:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Disclose ToRequest From
Therapist:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Disclose ToRequest From
Name/Facility:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Disclose ToRequest From
Name/Facility:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Dr. Dorsky and providers have have my permission to share the following information (check all you agree to):
Mental Health Diagnosis and/or TreatmentSocial HistoryAcademic/Educational HistoryMedical HistoryPsychological/Neuropsychological HistoryOther
I authorize Dr. Dorsky and providers to share information as indicated above. I am aware that Dr. Dorsky and providers cannot control how the recipient uses or shares the information, and that laws protecting its confidentiality at Dr. Seth M. Dorsky MD, LLC practice may or may not protect this information once it has been shared. Information will not be shared or collected without a valid signature below. I can cancel this authorization in writing at any time, except to the extent that information has already been released.
This authorization will expire one (1) year from signature date unless otherwise specified here.
Authorization Valid Until:

MonthDayYear
Date
Patient signature is required for patients who are 18 years or older, or who have emancipated minor status, or a special condition defined by law. Parent or legal guardian signature is required for patients under age 18 without emancipated status or a special condition.
Patient Name:

First NameLast Name
Signature of Patient

Clear
Date

MonthDayYear
Parent or Legal Guardian Name:
Signature of Parent or Legal Guardian

Clear
Relationship to Patient:
Date

MonthDayYear
Should be Empty: