Release of Information Form

Release of Information
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Please complete a separate form for each individual / entity

I authorize Jacksonville Neuro and Clinical Psychology Group and all of its affiliated providers to disclose or obtain health information as identified below:
Name*

First NameLast Name
Phone Number*
Email Address*
Relation*
Information to Release*

All RecordsInformation obtained during the course of therapy including therapy notesInformation obtained during neuropsychological testing and all reports pertaining to neuropsychological evaluationOther
For the purposes of: *

Personal UseInsuranceContinued CareLegalOther
Revocation*

I understand that I may revoke this authorization at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization.
Signature*
Print Name*

First NameLast Name
Relation to Patient*
Date*

MonthDayYear
Date
Once signed and all other required fields are complete, you may click "Submit" below, even if you still see a required field notice in red underneath the Signature field.
Should be Empty: