Release of Information Form

Authorization for Release of Confidential Information
Patient Name*

First NameLast Name
Guardian Name (if applicable)

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient or Guardian Email*
example@example.com
I authorize the organization or individual(s) listed below, to release, obtain, or release and obtain the requested information to Behavioral Learning LLC.
Please select one.*

ObtainReleaseObtain and Release
Contact Name*

First NameLast Name
Name of Affiliated Organization
Phone Number of Organization Contact/Individual*
Email Address of Organization Contact/Individual*
Address of Organization/Individual

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Delivery Method*
Type of information to be released:*

Assessment(s)IEP/504Progress ReportsTreatment PlanPermanent RecordDiagnosesPrescribed MedicationsOther
For the following purpose:*

Continued Medical CareLegal PurposesInsurance PurposesPersonal InterestOther
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:

Authorization for Release of Confidential Information