Release of Information Form

Release of Information Form

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

First NameLast Name
DOB

MonthDayYear
Birthday
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Provider/Agency/Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax
I hereby authorize the above listed Provider/Agency/Organization to*

Release information toReceive information fromExchange information with
FAMILY FIRST MENTAL HELATH (Corey) 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 RecordMental Health Assessments/EvaluationsSchool RecordsIndividual Education PlansAftercare or Discharge PlanningLegal or Custody AgreementPsychological EvaluationsSubstance Abuse AssessmentsEducational InformationAnnual Physical InformationMedication InformationTreatment 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

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Date

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

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

Release of Information Form

This release will expire one (1) year from the date hereof unless otherwise noted.