Authorization for Release & Exchange of Information

Authorization for Release & Exchange of Information
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Last 4 of Social Security Number
Is this information about you?*

YesNo
Name of Person Other Than Patient Requesting Records:
Enter your name
What is your relationship to the Patient?
From Date*

MonthDayYear
Date
To Date*

MonthDayYear
Date
Name, Address, & Phone with / from whom we should share these records:*
Why is this information needed (select all that apply)?*

Continue care or treatmentConsultation with another providerCoordinate care among providersDocument for legal reasonsVerify education servicesVerify employmentOther
What information is needed (select all that apply)?*

Medical treatment recordsMental health treatment recordsPsychological evaluation reportDischarge records / reportsSpecial education recordsRaw psychological test data (ONLY from psychologist to psychologist)
I hereby authorize the release of these records to Greg Hupp, Ph.D., a licensed psychologist, for the reasons checked above. Unless otherwise specifically stated, I also consent to the release of information regarding HIV/AIDS and chemical dependency / substance abuse diagnosis and treatment. This consent shall expire ninty (90) days from the date signed below.
Signature of Authorized Person

Clear
Date

MonthDayYear
Date
Should be Empty: