Release of Information Form

Authorization for Release of Confidential Information
Patient Name

First Name Last Name
Guardian Name (if applicable)

First Name Last Name
Patient Date of Birth

Month Day Year
Email
example@example.com
Type of information to be released:

Assessment(s) IEP/504 Progress Reports Treatment Plan Permanent Record Diagnoses Prescribed Medications
I authorize the organization or individual(s) listed below, to release the requested information to Behavioral Learning LLC.
Contact Name

First Name Last Name
Name of Affiliated Organization
Phone Number of Organization Contact/Individual
Email Address of Organization Contact/Individual
Delivery Method
Address of Organization/Individual

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
For the following purpose:

Continued Medical Care Legal Purposes Insurance Purposes Personal Interest
Consent

I understand that this release is valid from the date it is signed and expires within 1 calendar year from said date. I may withdraw my consent to this release at any time either orally or in writing.
Signature

Clear
Should be Empty:

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Authorization for Release of Confidential Information