Authorization to release healthcare information

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
If you would like Sunbreak Therapy Services to communicate with and share evaluation reports and/or progress reports with other medical professionals; Pediatricians, Therapists, School, etc., please complete this form.
I hereby authorize SUNBREAK THERAPY SERVICES to use and disclose and/or receieve specific health information regarding:
Patient's Name
Date of Birth

MonthDayYear
Date
To/From:
medical professionals; Pediatricians, Therapists, School, etc.
Address:
City
State
Zip Code
Phone #
Fax #
This request and authorization apply to: Please INITIAL all that apply
INITALS Healthcare information relating to the following treatment, condition, or dates:
treatment, condition, or dates
INITIALS Entire Medical Chart
INITALS Entire Mental Health Chart
INITALS Entire Mental Health Testing
I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer be protected under federal law. I also understand that federal or state law may restrict disclosure ofHIV/AIDs information, mental health information, genetic testing information and drug/alcohol diagnosis,treatment or referral information.

You may revoke this authorization in writing at any time. If you revoke this authorization, the information above may no longer be used or disclosed for the purposes described in this authorization. To revoke this authorization, please send a written request to Sunbreak Therapy services at PO Box 946 Canby, OR 97013. Unless revoked earlier, this consent will expire 1 year from the date of signing or shall remain in effect for the period reasonably needed to complete this request.
Unless revoked, this authorization expires Date (insert date or event). I have read and understood this information.
Patient/Parent/Legal Guardian Signature

Clear
Date

MonthDayYear
Date
Printed Name of Patient or Authorized Representative
Should be Empty:

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION