Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information
As noted below the following are authorized to:

Disclose InformationReceive InformationExchange Information
Regarding (Client Name)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name of Person Authorized to Disclose/Receive/Exchange Information*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Purpose of Disclosure- Select one

Continuity of CareDisability DeterminationOngoing TreatmentTreatment PlanningCollateralSubpoena/Legal
Information to be Disclosed
Amount of Information to be Disclosed

Most recent episode of carePrevious three monthsOther, specify
Other specified amount of information
I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon S.P.A.S.M. Acupuncture receipt of the written revocation.
Select one of the following

This authorization will expire upon the termination of treatment & services at S.P.A.S.M ACUPUNCTUREThis authorization will expire upon the disposition of the crisis assessment / crisis intervention & coordination of care .This authorization will expire when (specify below)This authorization will expire on (specify below)
Specifications (condition/date corresponding to above selection)
Signature*
Date signed*

MonthDayYear
Date
Should be Empty: