Release of Information Form

Authorization for Release of Confidential Information from Strength in Diversity Therapy Center Phone: 319-449-1444 | Fax: 319-409-8260

To:*

Provider / Clinic / Hospital Name

Phone Number:*

Provider Contact Number

Patient's Full Name: *

Please use your name as it appears on your Driver's License or Photo I.D.

Patient's DOB:*

MonthDayYear

Patient's Former Full Name: (if applicable)

Maiden or Former Names

Patient's Address:*

Address

Street Address Line 2

CityState

Zip Code

I hereby authorize and request the Strength in Diversity Therapy Center to release information regarding my therapy records, including assessment results, office notes, and treatment plans. I understand that this authorization will expire in 6 months and that it may be revoked at any time in writing. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient or third parties and no longer protected by the HIPAA privacy rule.

I acknowledge that my records may include sensitive material. Therefore, I request that you include the following records if any:

AssessmentTherapy notesTherapist consultationTreatment Plan

Consent:

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.

Patient's / Legal Guardian's Signature: *

Please draw your signature with your finger or mouse.

Relationship to Patient:

If Legal Guardian/Representative is signing