Release of Information Form

Expert Psychological Associates, LLC

George Zaky, Psy.D., LMHC, LLC 447 NW Prima Vista Blvd. Port St. Lucie, FL. 34983
Release/Receive Records
This form, when completed and signed by the patient or legal guardian, authorizes Expert Psychological Associates, L.L.C. / George Zaky, Psy.D., LMHC, L.L.C. to receive protected information from a third party and/or to release protected information from your clinical record to the person or entity you designate, as permitted under Florida law and federal regulations (including HIPAA, 45 C.F.R. Parts 160 and 164). Any mental health or substance‑abuse information released must comply with applicable Florida Statutes and, where relevant, the heightened protections of 42 C.F.R. Part 2. Only the specific persons or agencies listed on this authorization will receive the information.

Certain categories of information—such as HIV‑related information, and reports of child, elderly, or disabled abuse—are subject to additional statutory restrictions. You have the right to inspect and/or obtain a copy of the protected health information to be disclosed, as provided under 45 C.F.R. §164.524. Records are typically released within 30 days of receiving a valid authorization and any required fees, in accordance with Florida Administrative Code Rule 64B19‑19.005 and applicable federal law. Reasonable fees may be charged for copying, preparing, or transmitting records as permitted by law.

Prohibition on redisclosure: The information disclosed may be protected by federal and state confidentiality laws. Federal and state rules prohibit further disclosure of this information without your specific written authorization, unless otherwise permitted by 42 C.F.R. Part 2 or Florida Statute §394.4615. A general medical release is insufficient for this purpose. Federal law also prohibits the use of substance‑abuse treatment information to criminally investigate or prosecute any patient (42 C.F.R. §2.32). Florida law requires that any person or agency receiving this information maintain its confidentiality and exempt it from public‑records disclosure (§394.4615(6), F.S.). Facilities or practitioners who release information in good faith pursuant to this authorization are not subject to civil or criminal liability.

If this authorization results in the release of protected information to a third party, I understand that charges or fees may apply. I further understand that if I authorize the release of information via fax, email, or other electronic means, confidentiality cannot be guaranteed. I hereby release Expert Psychological Associates, L.L.C. / George Zaky, Psy.D., LMHC, L.L.C., and its staff from any liability arising from the release of information as directed by this authorization.
Take a clear photo of your ID
Patient Name

First NameLast Name
Representative/Guardian Name (if no rep/guardian, write the patient's name instead)

First NameLast Name
Patient's Birth Date

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Patient's Last 4 SSN
Type of Information to be Released (if not specific, write ALL)
(List as specifically as possible, for example: name, dates of service, any documents).
Purpose for Information Release
(List as specifically as possible, for example: to receive benefits).
Release Information to the Following (who is receiving the information?)
Who do you want us to release/receive/communicate from? (select below)
NAME & ADDRES of the person or agency you want to release/receive/communicate with on your behalf

First NameLast Name
Organization
Phone Number
Email Address
Delivery Method
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Continued Medical Care

Other
Release Date Expiration

MonthDayYear
Date
Consent
Signature
Name of the person signing this form (must be the patient's signature or his/her legal guardian)

First NameLast Name
Phone Number of the person signing this form

Area CodePhone Number
Should be Empty:

Expert Psychological Associates, LLC

Release/Receive Records

Release Information to the Following (who is receiving the information?)