Release of Protected Health Information

Release of Protected Health Information
Authorization to release:
Patient Name*

First NameLast Name
Date of Birth (DOB)*

MonthDayYear
Date
TOFROM
Facility/Person*
Phone Number
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Address
Individual(s) or Facility authorized to use or disclose the information:

Cognitive Behavior Institute: 125 Emeryville Drive, Suite 230, Cranberry Twp, PA 16066

Phone: 724-609-5002 Fax: 724-299-8964
Dates of service:*
Authorization to release:*

Verbal CommunicationWritten CommunicationMedication RecordsPhysician OrdersMedical HistoryPsychiatric/Psychological EvaluationPsychological Testing ResultsProgress SummaryDischarge SummaryOther
I understand this authorization may be revoked at any time by giving verbal and/or written notice to both parties. I understand release of my records will be for the purpose states on this form. Only those items checked off or listed will be released. A photocopy of this authorization shall constitute a valid authorization. I understand that once my records have been released to the party I choose they cannot be retrieved and I hereby release both parties listed above from all liability which may arise as a result of this authorization.
This agreement is valid for one year after the signature date below. If applicable, specify other expiration date/event here:
Patient Signature:*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Legal Guardian/Representative Signature (if applicable):

Powered by Jotform SignClear
Date

MonthDayYear
Date
If applicable, relationship to patient:
Should be Empty:

Release of Protected Health Information

Authorization to release: