Release of Information Form

Release of Information

This form permits an established patient's NBH clinician to obtain and/or release information to other parties (primary care clinician, therapist, dietician, school, etc.)
Patient Name *
Date of birth *

Month Day Year
Date
*

I DO authorize Norwood Behavioral Health to OBTAIN information from: I DO NOT authorize Norwood Behavioral Health to OBTAIN information from:
CLINICIAN/SCHOOL/ETC. NAME *
CLINICIAN TYPE (Therapist, Dietician, etc.) *
PHONE *
EMAIL
example@example.com
CLINICIAN/SCHOOL/ETC. NAME
CLINICIAN TYPE (Therapist, Dietician, etc.)
PHONE
EMAIL
example@example.com
CLINICIAN/SCHOOL/ETC. NAME
CLINICIAN TYPE (Therapist, Dietician, etc.)
PHONE
EMAIL
example@example.com
*

I DO authorize Norwood Behavioral Health to RELEASE information from: I DO NOT authorize Norwood Behavioral Health to RELEASE information from:
CLINICIAN/SCHOOL/ETC. NAME *
CLINICIAN TYPE (Therapist, Dietician, etc.) *
PHONE *
EMAIL
example@example.com
CLINICIAN/SCHOOL/ETC. NAME
CLINICIAN TYPE (Therapist, Dietician, etc.)
PHONE
EMAIL
example@example.com
CLINICIAN/SCHOOL/ETC. NAME
CLINICIAN TYPE (Therapist, Dietician, etc.)
PHONE
EMAIL
example@example.com
For dates starting: *

Month Day Year
Date
And ending *

Until care is terminated Enter date below
Through:

Month Day Year
Date
INFORMATION INCLUDES, BUT IS NOT LIMITED TO:

Diagnosis, prognosis, or treatment data; initial interview, treatment summaries, discharge summary, psychological assessment; or other information.

I understand that my records are protected under federal and Massachusetts laws and cannot be disclosed without my written consent except as otherwise specified by these laws. Furthermore, I understand that if my records involve alcohol or drug abuse they are also prohibited under the Federal Reg. 42CFR, confidentiality of alcohol and drug abuse.

I have carefully read and understand the above statements and do herein consent to disclose the above information, including alcohol and drug abuse records, if relevant, to those persons/agencies named above.

I further release Norwood Behavioral Health from any liability arising from the release of this information to such persons/agencies, provided that said release of information is done substantially in accordance with applicable laws. I understand that I may revoke my consent at any time. This revocation will only affect future disclosure or release of information.
Client/Parent/Guardian signature:

Clear
Print name *
Date *

Month Day Year
Date
Should be Empty: