Consent For Release Of Information

CONSENT FOR RELEASE OF INFORMATION
I hereby authorize (Name and address of clinician)
to release information from the records of
(name of Patient)
for the purposes of
The information to be released is
Summary of TreatmentPsychosocial HistoryNeuropsychological EvaluationOther related psychologicalOther (specify)
PLEASE FORWARD INFORMATION TO THE ATTENTION OF: (Name and Address of facility or person)
I have been told that, in order to protect the confidentiality of records, my agreement to obtain or release information is necessary and that this permission is limited for the purposes and to the person listed above, and will be effective during the dates listed below. I also understand that this consent is revocable except to the extent that action has been taken in reliance thereon.
This consent shall be if effect from
Until (Not to exceed 1 year)
(Signature of Patient) (Parent or Guardian)

Clear
Date of Signature

MonthDayYear
Date
(Signature of Witness)

Clear
Date of Signature

MonthDayYear
Date
Should be Empty:

CONSENT FOR RELEASE OF INFORMATION