Release of Information Form

AUTHORIZATION FOR RELEASE OF RECORDS
Authorization for the use and disclosure of Protected Health Information (PHI) is only for the person or agency on this form.
Patient or Client Name
DOB
Address
Phone
Email
example@example.com
Provider/Agency/Organization*
Please list the provider or organization that will be releasing the information
Address*
Phone*
Fax
I hereby authorize the above listed Provider/Agency/Organization to*

Release information toReceive information fromExchange information with
CP COALITION LLC (Venus Allen, LCSWA, LCASA, CMC) any and all medical, confidential, employment or other information requested regarding the above-named individual which it has in its possession. I also consent to this information being exchanged by means of electronic communication such as email or an electronic health records (EHR) portal.
The disclosure is to be used for:*

Immunization RecordPsychological EvaluationsMental Health Assessments/EvaluationsSubstance Abuse AssessmentsSchool RecordsEducational InformationIndividual Education PlansAnnual Physical InformationAftercare or Discharge PlanningMedication InformationLegal or Custody AgreementTreatment Plans
I understand that if the organization authorized to receive information is not a health plan or health care provider and if such information is re-disclosed by the recipient, the released information may no longer be protected by federal privacy regulations, but may be protected under federal and state law.
- I understand that this authorization is voluntary.
- I understand that the client’s health care and payment will not be affected if I do not sign this form.
- I understand that I may receive a copy of this form after I sign it and that I may inspect and request a copy of the information I am authorizing for use or disclosure.
- I understand that these records are to be kept confidential and the information is for use by that action has been taken in reliance upon it.
- I understand and agree that this release may contain information pertaining to psychiatric, drug and/or alcohol diagnosis and treatment.
- I understand that I may revoke my consent in writing at any time, except to the extent that an action has been taken in reliance upon it.
Authorized Signature

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature (Required if patient is a minor)

Clear
Date

MonthDayYear
Date
This release will expire one (1) year from the date hereof unless otherwise noted.
Should be Empty:

AUTHORIZATION FOR RELEASE OF RECORDS