Authorization to Exchange Information

Authorization to Exchange Information

Authorization used if request is made to exchange information with another person or entity.
I * authorize the release of information between Lorraine Crockford, PHD. LMFT on behalf of *, and the identified person, entity or facility listed below during the time I am in treatment with this clinician until treatment expires/or if I revoke this authorization in writing.
My relationship to the above:*

SelfParentLegalOther
If "Other" was chosen, please explain:
Name of Person/Facility to receive health information:*
I understand the purpose of this release will be specifically used diagnostically and in the coordination of mental health treatment with other mental health practitioners involved throughout the time I myself and/or the above patient is in treatment. This release can include treatment progress, medical records, history of treatment, assessments, diagnosis, and treatment planning.
I wish to release the following information only.
Please specify:
I understand the use of disclosure of my individually identifiable health information is as described above for the purpose listed.
I understand that I may revoke this release at any time through written communication.
I am signing this release voluntarily.
I understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose medical/mental health information unless another authorization is obtained by me or unless such disclosure is specifically required or permitted by law.
Signature of Patient

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Signature of Parent/Guardian/Legal Representative

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