Release of Information

Person Served

Date of Birth

SSN

I hereby authorize the disclosure of information from Emotional Wellness Department at Community Health Partners to:

Organization or Person to Receive Information

Address

City, State, Zip Code

Telephone Number

Reason for Request

Continuity of CareOther

Other

I authorize the disclosure of information dates of service

Date

Description of Dates of Service to Be Disclosed (example: 1/1/00-present)

I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign this

authorization and do not need to sign this form in order to receive treatment. I acknowledge that I give consent to this disclosure as described above. I understand that I have the right to revoke this authorization at any time in writing. I understand that revoking this authorization will not affect any actions already taken on it. I understand that I am entitled to receive a copy of this authorization upon request. Each disclosure requires an additional signed authorization. This consent will expire 180 days after the date of my signing. I hereby agree to hold Community Health Partners and its clinicians harmless for any liability that may result directly or indirectly from the disclosure released in accordance

Signature of Person Served or Parent/Guardian

Date