Release of Information

Jeffrey Nelson, LCSW, PLLC
1805 S. Bellaire St., Ste. 219, Denver, CO 80222

RELEASE OF INFORMATION

This document, signed by the client, allows information to be shared by the client's therapist to a third party. Information may also be shared from the third party to the client's therapist.

I,

Full Name*

First NameLast Name

Patient/client email*

example@example.com

Date of birth*

Date

agree to allow Jeffrey Nelson, LCSW, to release the following information regarding my (my child's) treatment, including information about diagnosis, medical information, history, previous treatment, current treatment & progress, for purposes of further evaluation and/or continuity of care. Information may also be obtained from the third party by the therapist. Use this space for specific instructions regarding information to be shared if necessary.

PLEASE NOTE: By law, this document can only have one name/entity identified below with whom information may be exchanged:

Primary Care Physician:*

NoYes

One or the other, not both.

Psychiatrist:*

YesNoN/A

if yes, write name and contact number

If using insurance, information must be provided to for ongoing authorization & billing. Please indicate the Name of your Insurance Company:

Other individual(s) with whom information may be exchanged (please write names and contact #'s) IF NEITHER PRIMARY CARE PHYSICIAN OR PSYCHIATRIST NOT IDENTIFIED ABOVE:

Signature of Client (parent if under 18)*

Date*

Date

Signature of Client

Date