In authorizing this release of information, I understand that my records are protected uner Federal and Specific State Confidentiality laws and cannot be disclosed without my written consent unless otherwise provided for in regulations.
The unauthorized disclosure of mental health information violates the provisions of the Maryland Medical Records Act. Disclosures may only be made pursuant to a valid authorization by the client or as provided in Title IV of that Act. The Act provides for civil and criminal penalties for violations.
This authorization releases Stephanie Weiland LLC from any and all legal liability that may arise as a result of their compliance with my request. This consent is subject to revocation at any time except that action has been taken in reliance thereon.
My signature below attests to the fact that I have read this form, understand its content and request that the above information be released as specified. I further acnowledge that the information to be released was fully explained to me and the consent is given of my own free will.
I understand that written treatment intake notes and written treatment progress notes are not released as part of this Authorization for Release of Information.