Release of Information Form

Authorization for Release of Information
Client Name*

First NameLast Name
Client Birth Date*

MonthDayYear
Client Phone Number*

Area CodePhone Number
Today

MonthDayYear
Date
Days
Age
Last 4 SSN

Release Information to the Following
Authorization for Release*

I authorize Norcon Family Counseling to release the above information to the person or entity listed below.I authorize the person or entity listed below to release the above information to Norcon Family Counseling at 20 Westwoods Dr., Liberty, MO 64068. Phone Number: 816-781-2349. Fax Number: 816-782-8232, Email: norcon@norconfc.com.
Name

First NameLast Name
Organization
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mark any types of preferred delivery method if applicable

FaxEmailUSPS MailPhoneOther

Consent to Release
1. I understand that this release is voluntary and that I may refuse to sign this authorization.
2. If the person or organization I authorize to receive the information is not subject to federal health information privacy laws, they may further release the protected health information and it may no longer be protected by the federal privacy laws.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken before the revocation is received.
4. My treatment, payment for healthcare, enrollment in a health plan or eligibility for benefits may not be conditioned on signing this authorization.
5. I may see and copy the information described on the form upon my request.
6. I may refer to the Notice of Privacy Practices to get more in-depth information regarding my privacy rights.
I have carefully read and understand the above statements and do herein expressly and voluntarily consent to disclosure of the above informaton about, or medical records of, my condition to those persons or agencies named above.
Client Name*

First NameLast Name
Client's Signature

Clear
Parent or Guardian's Name

First NameLast Name
Relationship to Client
Parent or Guardian's Signature

Clear
Date

MonthDayYear
Date
Should be Empty: