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:
Regarding (Client Name)

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Program/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.Format: (000) 000-0000.
Email
example@example.com
Name of Program/Person Authorized to Receive/Disclose/Exchange Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Purpose of Disclosure- Select one

Other
Information to be Disclosed
Other specified information or limitations of shared information
Timeframe for Disclosure

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
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Release of Information - Lauren Hutchinson, LMFT