Release of Information Form

Authorization to Use or Disclose Protected Health Information
Completion of this document authorizes the disclosure and use of health information about you. Failure to provide all information requested may invalidate this authorization. This authorization expires 1 YEAR after the date it's signed, unless otherwise specified: Expiration date
Patient's Name*

First NameLast Name
Patient's birthdate*

MonthDayYear
RELEASE OF HEALTH INFORMATION TO THE FOLLOWING INDIVIDUAL
Name: Relation to patient:
USE AND DISCLOSURE OF HEALTH INFORMATION
I hereby authorize Arise Psychiatric Medical Group
to SEND records TO:
Person/Organization authorized to receive information
Phone number
Fax number
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
to RECEIVE records FROM:
Person/Organization authorized to receive information
Phone number
Fax number
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Include the following information*

ALL health information pertaining to my medical history, mental or physical condition and treatmentOR only the following records or types of health information (including any specific date ranges):
I specifically authorize the release of the following information (initial as appropriate):

Initials* Mental health treatment information

Initials* Psychotherapy notes
Initials HIV test results

Initials Alcohol/drug treatment information
Signature*

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Date*

MonthDayYear
Date