Release of Private Health Information

Release of Information - Lauren Hutchinson, LMFT

Authorization to Use and Disclose Confidential Protected Health Information
As noted below, the following individual or organization is authorized to:

Disclose Information Receive Information Exchange Information
Regarding (Client Name)

First Name Last Name
Date of Birth

Month Day Year
Date
Name of Program/Person Authorized to Disclose/Receive/Exchange Information
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Name of Program/Person Authorized to Receive/Disclose/Exchange Information
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Purpose of Disclosure- Select one

Continuity of Care Ongoing Treatment Treatment Planning Consultation Other
Information to be Disclosed

Attendance/participation Crisis Assessment Progress in Treatment Psychiatric Evaluation Neuropsychological Evaluation Information on Mental Health and/or Treatment Other, please specify below Medical or School Records
Other specified information or limitations of shared information
Timeframe for Disclosure

Six months from date signed One year from date signed Other
Specify any limitations to shared information here:
I authorize the release of my confidential protected health information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is
covered by state laws that limit the use and/or disclosure of my confidential protected health information.
Signature of Client (age 13 and older)
Person signing

Client Guardian Self
Date signed

Month Day Year
Date
Should be Empty:

Release of Information - Lauren Hutchinson, LMFT