Client's Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose of Disclosure
Coordination of Care
Other
Information to be released:
Summary of treatment to date
Report
Other
Persons authorized to make disclosure
Person authorized to receive disclosure
Method of Disclosure
Written:
Verbal:
Electronic:
Today's date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization to expire on:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Patient
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Personal Representative
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