AUTHORIZATION TO OBTAIN AND RELEASE INFORMATION

AUTHORIZATION TO OBTAIN AND RELEASE INFORMATION
In order to provide the best care possible, Dr. Seth Dorsky needs 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 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 Name Last Name
Phone Number *

Area Code Phone Number
Date of Birth *

Day Month Year
Address

Street Address

Street Address Line 2

City State / 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 To Request From
Primary Care Provider:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Disclose To Request From
School:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Disclose To Request From
Therapist:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Disclose To Request From
Name/Facility:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Disclose To Request From
Name/Facility:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Dr. Dorsky has my permission to share the following information (check all you agree to):
Mental Health Diagnosis and/or Treatment Social History Academic/Educational History Medical History Psychological/Neuropsychological History
I authorize Dr. Dorsky to share information as indicated above. I am aware that Dr. Dorsky cannot control how the recipient uses or shares the information, and that laws protecting its confidentiality at Dr. Dorsky’s 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:

Month Day Year
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 Name Last Name
Signature of Patient

Clear
Date

Month Day Year
Parent or Legal Guardian Name:
Signature of Parent or Legal Guardian

Clear
Relationship to Patient:
Date

Month Day Year
Should be Empty: