Authorization for Release of Health Information

Authorization for Release of Health Information

Also known as Protected Health Information (PHI)
Carolina Anxiety Care

M. William Futtersak, Ph.D. Clinical Psychologist
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Information to be released to? (Name, Address, Telephone/Fax/Email) *
Relationship of Person/Agency receiving information?*
Family member? Psychiatrist? Primary Care Physician?
Purpose of Disclosure*
Information to be Released (check all that apply)*

Participation in PsychotherapyEvaluation/Diagnostic InformationTreatment PlanProgress in PsychotherapyNeed for Follow-Up/Referral
Manner in which information may be disclosed? (check all that apply)*

VerbalTelephoneFaxEmailSMS/text
I understand that, unless withdrawn, this authorization will expire 180 days from the date of my signature. An electronic version or photocopy of this form will be considered as valid as the original.

I understand that I may revoke this authorization at any time by notifying Waxhaw Anxiety Care or Dr. M. William Futtersak in writing or by electronic means (e.g., email, text, fax).
By signing below, I acknowledge that I have read and understand this authorization.
Today's Date*

MonthDayYear
Date
Signature of Patient*

Clear
Signature of Patient's Parent/Legal Guardian (if patient is a minor)

Clear
Name of Parent or Legal Guardian (if patient is a minor)

First NameLast Name
Should be Empty:

Carolina Anxiety Care