RELEASE/REQUEST OF INFORMATION

1627 N. Swan Rd. #101

Tucson, Arizona 85712

Telephone: 520.344.0056

E-mail: SunlightDesk@gmail.com
Release of Information
I, YOUR NAME* hereby authorize Sunlight Center for Change, LLC, to
Choose one:*

RELEASEREQUESTRELEASE AND REQUEST
the following information concerning Client Name* Date of birth , to/from:
Name of Person, Agency/Company/Hospital:*
Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency Phone Number*
Please enter a valid phone number.
Agency Email
example@example.com
This information is to be released/requested for the following purpose(s):*

Entire RecordDischarge SummaryTreatment SummaryTreatment PlanningProgress NotesDiagnosisLab ResultsMedication InformationAttendanceVerbal Communication OnlyFinancial InformationPsychological TestingWritten CommunicationAssessment Information
Your Signature:*

Powered by Jotform SignClear
Printed Name:*

First NameLast Name
I am the (check one):*

ClientCustodial ParentLegal GuardianLegal Custodian of Record
Date*

MonthDayYear
Date
Email*
example@example.com
This release shall expire (check ONE)*

In one yearUpon Termination of careOn specific date set below
Date*

MonthDayYear
Date
Notice to Recipient: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. If the information to be released pertains to the diagnosis and treatment of mental health, alcoholism, and or substance addiction/abuse, I understand that the confidentiality of the information is protected by Federal Law. Federal regulations (42 C.F.R. Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.
Should be Empty:

Release of Information