Release of Information

CLIENTS NAME:

Date of Birth:

Date

Today's Date

Date

Requesting Entity:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Fax Number

Area CodePhone Number

Releasing Entity:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Fax Number

Area CodePhone Number

Phone Number

Area CodePhone Number

(initial) I authorize this release to be reciprocal between the two parties.

Initial

INFORMATION AUTHORIZED FOR RELEASE

I hereby authorize the above information to be released to the party I have indication for the purpose of

Other

I retain the right to revoke this authorization in writing prior to the expiration date below.

Treatment may not be conditioned on obtaining the authorization if that is prohibited by the HIPPA Privacy Rule.The information disclosed pursuant to this authorization may be subject to re-disclosure by the designated recipient, and subsequently no longer protected by the HIPAA Privacy Rule. I understand that authorizing the disclosure of the above information is voluntary and I need not sign this form to ensure treatment.

Signature of Client or Client’s Designee

Signature of Client or Client's Designee

Designee’s Relationship to Client

Designee's Relationship to Client

Witness

Date Authorized

Date

Date Authorization ends

Date