Authorization to Release Healthcare Information

Authorization to Release Healthcare Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SSN#
MR#
Email
example@example.com
Authorization
By signing this form, I request and authorize release and management of healthcare information between Dr. Robin Shaw and

(add who you want information shared with below)
Name:
Person to receive protected information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
This document expires in one year from today's date unless otherwise specified. I also understand I may revoke this authorization at anytime by notifying my provider.
Expires on:

MonthDayYear
Date
This release of information applies to:*

Medical InformationMental Health Information OnlySubstance Abuse and STDsVerbal ConsultationElectronic Transmission of InformationLegal RecordsOther
Information will be released for the purposes of:*

Meeting financial obligations of treatmentUpdating progress in treatmentNotifying significant other of crisis situationContinuing careTreatment planningCompleting assessmentVerbal reports on course of treatmentOther
This release of information

Financial information regarding treatmentNotification of crisis/AWOL/AMA situationsMaster Treatment PlanVerbal reports on course of treatmentProgress NotesDischarge SummaryDiagnostic SummaryDrug and alcohol history and/or STDOther
I, the undersigned, understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it, and that in any event, this authorization shall expire six (6) months after the date signed unless otherwise specified.
Please specify date (if applicable)

MonthDayYear
Date
I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and to the best of my knowledge. Re-disclosure of my medical records by those receiving the above-authorized information may not be accomplished without my further written consent. When services are provided to more than one person simultaniously, legally neither the therapist or the records will represent either individual separately.
Patient Signature*
Today's Date

MonthDayYear
Date
Witness Signature
Today's Date*

MonthDayYear
Date
By checking this box, I voluntarily authorize the reciprocal release of confidential information between Robin P. Shaw, PhD, LPC, LCDC 1907 N. Lamar #354, Austin, TX 78705 and the name, address and phone number of person(s) or organization to receive/give confidential information listed below:
Should be Empty: