CONSENT TO REQUEST OR RELEASE

GENERAL CONSENT- DISCLOSE
Patient Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date of Birth
I authorize The Briarwood Clinic to REQUEST my protected records owned by:I authorize The Briarwood Clinic to RELEASE my protected to:
Individual and/or Agency Name*
The party you want us to request or release records
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

CityState

Zip Code
Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Intake Evaluation & DiagnosisTest Results / Treatment PlanMedical records/psychotherapy NotesEntire Patient RecordSchool/Employment/Military RecordsVERBAL/WRITTEN COMMUNICATION
Only include records in this date range:Date Date OR ALL RECORDS (no date restrictions)
AIDS/HIV infectionGenetic InformationMental Health RecordsCommunicable diseaseTreatment for alcohol and/or substance abuseSexually Transmitted diseases
Signature of Patient / Parent / Legal Guardian*

Clear
Date of Signature:*

MonthDayYear
Date
Name of Individual Signing:*

First NameLast Name
Upload picture of Driver's License or picture I.D. that includes signature. Include any legal documents proving guardianship (if applicable).

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GENERAL CONSENT- DISCLOSE