Release of information - Dana Group Associates

Authorization for release of confidential information

Dana Group Associates
Client name (first name, last name) *
Client DOB *

Month Day Year
Date
I hereby authorize Dana Group Associates *

to obtain from to disclose to to exchange with
Outside provider name and / or facility name *
Outside provider / facility address *
Outside provider / facility phone number *
Outside provider / facility fax number *
The information contained in the confidential records of the above named provider or facility pertaining to services provided during the time period from: _____ to _______
(e.g., start of treatment to present)
Please check the information that you authorize to be released to or exchanged with Dana Group Associates. *

Intake / Admission Notes Progress notes Treatment plans Laboratory data Psychiatric evaluation Psychological testing History and physical exam Drug and alcohol records Psychoeducational testing Education record Police report Discharge / Closing summary
The information is needed for the following purpose(s): *

To provide ongoing treatment / aftercare To obtain insurance or financial assistance To enable judges, attorneys, probation / parole officer to support treatment goals Referral of client for services
I understand that the confidentiality of my records is protected under Federal Regulations (42CRF, Part 2). I have read carefully and understand the above statements and do herein expressly and voluntarily consent to disclosure of the above information and / or medical records to these persons/agencies named above.
Signature of client or authorizing legal guardian *

Clear
Relationship to client *
(e.g., self, mother, father, parent, etc.)
Date signed *

Month Day Year
Should be Empty:

Authorization for release of confidential information