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*

MonthDayYear
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)*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Signature of Client

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty:

RELEASE OF INFORMATION