Consent for release of information

REQUEST/AUTHORIZATION TO RELEASE CONFIDENTIAL RECORDS AND INFORMATION
This form, when completed and signed by you, authorizes the release of protected health information from your clinical record to and/or from the person you designate. It cannot be used to re-release confidential information by other individuals or facilities. Such requests should be referred to the original individual or facility.
Name

First Name Last Name
Date of Birth

Month Day Year
Date
I authorize Carolina Psychological Associates, P.A. to:

Disclose information to Obtain information from Exchange information with
Person/Facility:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone Number:
The type of information to be disclosed:

Treatment summary Psychiatric Evaluation/Medication History Psychological evaluation results Medical history and evaluation(s) Educational records Other
The purpose of this disclosure is for:

Coordination of care Further evaluation/assessment/treatment Treatment planning Other
This consent is effective on blanks and expires on blank .
I have had explained to me and fully understand this request/authorization to release records and information, including the nature of the records, their contents, and the consequences and implications of their release. This request is completely voluntary on my part and will expire automatically after one year from the date on which it is signed. I have the right to revoke authorization, in writing, any time, except to the extent that action based on this consent has already been taken or if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
Client/Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Clinician Name
Should be Empty:

REQUEST/AUTHORIZATION TO RELEASE CONFIDENTIAL RECORDS AND INFORMATION